BackgroundRecent emphasis on value based care and population management, such as Accountable Care Organizations in the United States, promote patient navigation to improve the quality of care and reduce costs. Evidence supporting the efficacy of patient navigation for chronic disease care is limited. The objective of this study was to evaluate the effect of a patient navigation program on medical and administrative outcomes among patients with diabetes in an urban, safety-net hospital clinic setting.MethodsA retrospective cohort study with pre- and post-intervention periods was conducted. Eligible patients were those with A1C ≥ 8.5% and at least one appointment no-show in the previous 12 months. The intervention and reference groups were balanced on observed characteristics and baseline outcome levels using propensity score matching. The effect of patient navigation was isolated using the difference-in-differences approach. Primary outcomes were A1C, low-density lipoprotein cholesterol, triglycerides, random urine microalbumin, the number of scheduled appointments, clinic visits, emergency visits, and inpatient stays, and the percentage of arrivals, cancellations, and no-shows to scheduled appointments.ResultsOf 797 eligible patients, 328 entered the navigation program. Matching reduced the sample size to 392 individuals (196 in each group). Patient navigation resulted in improved A1C (−1.1 percentage points; p < .001), more scheduled appointments (+ 5.3 per year; p < .001), more clinic visits (+6.4 per year; p < .001), more arrivals to scheduled appointments (+7.4 percentage points; p = .009) and fewer no-shows (−9.8 percentage points; p < .001).ConclusionsNavigation was associated with improved glycemic control and better clinic engagement among patients with diabetes. Further research is important to identify what features of navigation in diabetes care are critical to achieving success and to understand navigators’ role in other settings.

This article deals with the puzzling fragment 24 in scroll 4Q541 for which many explanations have been proposed. A fresh examination of the text itself and a comparison to fragment 2ii+3+4i in the same scroll suggests that the topic of the fragment is a dove which seeks asylum from birds of prey. This examination also contributes to understanding some linguistic issues. In light of the semantic field of the verbs meaning ‘physical departure’, ‘forgiveness’ and ‘relinquishing a debt’ we learn about the development of the root מח״ל to the sense ‘to give over into the hands of’. In addition, the morphological form תמחולהי and the masculine form יון (a dove) are accounted for.

Primary ciliary dyskinesia (PCD) is a genetically heterogeneous recessive disorder caused by several distinct defects in genes responsible for ciliary beating leading to defective mucociliary clearance often associated with randomization of left/right body asymmetry. PCD individuals with defective radial spoke heads are difficult to diagnose due to lack of gross ultrastructural defects and absence of situs inversus . Thus far, most radial spoke mutations identified are loss-of function mutations, and missense variants have been rarely described. Using immunofluorescence analyses (IF), we studied the consequences of different RSPH9 , RSPH4A , and RSPH1 mutations on the assembly of the radial spoke complex to improve diagnostics in PCD. We identified bi-allelic mutations in RSPH9, RSPH4A and RSPH1 including 7 novel mutations comprising missense variants in 21 PCD individuals (16 families). We performed IF using antibodies directed against the radial spoke head components RSPH9, RSPH1 and RSPH4A to analyzed respiratory cilia of these patients. Absence of RSPH4A due to mutations in RSPH4A results in deficient axonemal assembly of the radial spoke head components RSPH1 and RSPH9. RSPH1 mutant cilia, lacking RSPH1 fail to assemble RSPH9, while RSPH9 mutations result in axonemal absence of RSPH9 but do not affect the assembly of the other head proteins RSPH1 and RSPH4A. Interestingly, our results were identical in individuals carrying loss-of-function mutations, missense variants or one amino acid deletion. Thus, we conclude that Immunofluorescence analysis can improve diagnosis of PCD in patients with loss-of-function mutations as well as missense variants.

AbstractSecond Samuel 4 describes the assassination of Ish-Bosheth, the last successor of Saul, by two of his brigade commanders. Verse 6 in this chapter gives the account of the actual killing. The verse has long been reckoned as problematic from the linguistic and literary points of view. Traditional Jewish commentators tried to solve the textual problem by means of syntactical completions. The Septuagint gives a different account here, which most scholars have adopted as original. A few, however, have raised the possibility that the Greek version is actually an attempt to solve the difficulties in the Hebrew text. In this article, I attempt to show that the Masoretic text is accurate and completely comprehensible. Furthermore, it sheds light on the entire scene, and brings to the front the personal attitude of the biblical narrator towards David and his kingship.

Air-fluidized support surface therapy has many drawbacks, such as dehydration, in an already difficult recovery for those wound patients who have undergone flap and graft surgery. In addition, patient care and handling are also problematic. Patients complain of discomfort, and the instability of the surface interferes with patient stability in side lying and semi-Fowler's positions. Alternative support surfaces can be considered for postflap or postgraft patients. Such technologies as alternating pressure, low-air-loss, and therapeutic nonpowered, advanced, and lateral rotation surfaces are widely used for pressure management in high-risk patients and those with existing pressure ulcers. These surfaces must be used within a total pressure ulcer management program that includes frequent turning and repositioning, skin and ulcer care according to evidence-based protocols, patient and caregiver instruction, nutrition, and offloading and positioning. The proposed recommendations require more research on the relative effectiveness of less expensive and more user-friendly support surfaces such as low-air-loss and nonpowered advanced support surfaces and is necessary in order to conclusively recommend one type of surface over another. However, at this time the available clinical studies and opinions remain positive.

A convenient screening test for children with bleeding symptoms before more labor-intensive diagnostic steps are taken would be of value. The Impact-R was designed in an attempt to analyse platelet function under near physiological conditions. Results are presented as surface coverage (SC, %) and average size (AS, microm(2)). In this cross-sectional retrospective study, we assessed the use of the Impact-R in the evaluation of children with a suspected bleeding disorder (BD). The hospital charts of 110 children referred to the coagulation laboratory were reviewed for personal and family bleeding history (BH) as well as results of the laboratory evaluation. A laboratory 'diagnosable' BD (LBD) was found in 23 children (21%, 95% CI 14-30%). A diagnosis of LBD was associated with the severity of bleeding but not with family BH. By receiver-operating characteristic (ROC) curve analysis, the SC was superior to the AS for diagnosis of a LBD. The Impact-R was abnormal in 43/97 children (44.3%, 95% CI 34-55%). The predictive values of a normal and abnormal Impact-R were 96% (95% CI 92-97%) and 42% (95% CI 28-56%), respectively. When considering the personal and family BH, the post-test probability for LBD after a normal Impact-R was reduced from 20% to 3.5% (95% CI 2.5-7%). A normal Impact-R test is highly effective in excluding LBDs. Yet, in case of an abnormal Impact-R test, further testing is needed. An algorithm that includes the personal and family BH and the results of a screening test may improve the diagnostic process. Prospective studies are now needed to confirm these findings.

This article explores the intertextual nature (as defined by Kristeva) of linguistic markers used to denote quotations (quotation markers) in the 1999 Israeli televised electoral campaign. Three kinds of quotation markers were identified: source markers (references, qualifiers), describing the source; speech markers (lexical, graphical), attesting to speech production; and circumstance markers, describing the context (time, place, participants, background) in which the quotation was produced. It was found that, in addition to their overt role as references to the quotation, quotation markers also encode the ideological and argumentative value attributed by the parties to the quotations and their sources. Source markers serve to affiliate the sources with the positively regarded “we” group, to exclude them, or to establish them as neutral; speech and circumstance markers serve to affiliate quotations with the positively regarded ideological text of the party, to exclude them, or to mark them as neutral. Moreover, these three markers serve to reinforce the reliability of quotations that fulfill a corroborative role. These values are encoded by the mere presence of the markers, as well as by such devices as variation in the frequency of the markers, their content, emotive connotations, grammatical forms, and incorporation in recurring patterns.

This article addresses issues related to acute myocardial infarction (MI) complicated by heart failure, particularly in elderly patients. Findings have shown that acute MI complicated by congestive heart failure (CHF) is associated with a high mortality, and that women with acute MI are more likely to be older and to develop CHF than men with acute MI. In general, management of CHF complicating acute MI is similar in older and younger patients. Actions discussed include hemodynamic monitoring; the administration of oxygen; and the use of morphine, diuretics, nitroglycerin, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, spironolactone, beta-blockers, calcium channel blockers, magnesium, digoxin, and positive inotropic drugs. The article also discusses measures for treating arrhythmias and for diagnosing mechanical complications.

Schizophrenia, a severe neuropsychiatric disorder, is believed to involve multiple genetic factors. A significant body of evidence supports a pivotal role for abnormalities of brain development in the disorder. Linkage signals for schizophrenia map to human chromosome 6q. To obtain a finer localization, we genotyped 180 single nucleotide polymorphisms (SNPs) in a young, inbred Arab-Israeli family sample with a limited number of founders. The SNPs were mostly within a approximately 7 Mb region around the strong linkage peak at 136.2 Mb that we had previously mapped. The most significant genetic association with schizophrenia for single SNPs and haplotypes was within a 500 kb genomic region of high linkage disequilibrium (LD) at 135.85 Mb. In a different, outbred, nuclear family sample that was not appropriate for linkage analysis, under-transmitted haplotypes incorporating the same SNPs (but not the individual SNPs) were significantly associated with schizophrenia. The implicated genomic region harbors the Abelson Helper Integration Site 1 (AHI1) gene, which showed the strongest association signal, and an adjacent, primate-specific gene, C6orf217. Mutations in human AHI1 underlie the autosomal recessive Joubert Syndrome with brain malformation and mental retardation. Previous comparative genomic analysis has suggested accelerated evolution of AHI1 in the human lineage. C6orf217 has multiple splice isoforms and is expressed in brain but does not seem to encode a functional protein. The two genes appear in opposite orientations and their regulatory upstream regions overlap, which might affect their expression. Both, AHI1 and C6orf217 appear to be highly relevant candidate genes for schizophrenia.