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Dartmouth, Lebanon

Christiano A.S.,One Medical Center Dr | Shessler E.M.,Dartmouth Hitchcock Pediatric Clinic
Adolescent Medicine: State of the Art Reviews | Year: 2010

Technologic advancements in the past decade have greatly improved our ability to manage diabetes, and made it practical to achieve tight control while providing a more flexible schedule and diet for children and their families. In this article, we discuss the recent advances in blood glucose monitoring, insulin analogues, and insulin delivery, as well as the new lexicon used by patients and the diabetes team. Copyright © 2010 American Academy of Pediatrics. Source

Holubar S.D.,One Medical Center Dr | Pendlimari R.,Mayo Medical School | Loftus Jr. E.V.,Mayo Medical School | Larson D.,Mayo Medical School | And 3 more authors.
Diseases of the Colon and Rectum | Year: 2012

BACKGROUND: We previously reported the costs associated with surgery for chronic ulcerative colitis in the Olmsted County population and found that direct medical costs after surgery were significantly reduced compared with before surgery. However, in that study, costs associated with chronic medical therapy for ulcerative colitis were not assessed in nonsurgical patients. OBJECTIVE: To gain insight into the drivers of costs of treatment for chronic ulcerative colitis, we assessed direct costs after surgical and medical therapy in 120 patients in the Rochester Epidemiology Project database. METHODS: A cohort of 60 patients who recovered from surgery for ulcerative colitis from 1988 to 2006 were 1:1 matched by age, sex, and referent year to medically managed patients. Direct health care costs were estimated from an institutional database, and observed cost differences over a 2-year period were calculated. Statistical significance was assessed by paired t tests and bootstrapping; mean costs are adjusted 2009 constant dollars. RESULTS: Two-year direct health care costs in the surgical and medical cohorts were $10,328 vs $6,586 (p = 0.19). In the surgical cohort, Brooke ileostomy patients were observed to have higher costs than patients with ileal pouches (Δ$8187, p = 0.04), and after ileal pouch, pouchitis was associated with increased costs (Δ$12,763, p < 0.01). In the medical cohort, disease extent (Δ$6059, p = 0.04) but not disease severity was associated with increased costs. LIMITATIONS: This study was limited by the relatively small population size and by its performance in a county with a tertiary referral center. CONCLUSIONS: Before the introduction of biologic therapies for ulcerative colitis, patients were observed to have similar health care costs after surgical and medical therapy. In medically treated patients, disease extent was associated with increased costs, whereas in surgically treated patients, permanent ileostomy and pouchitis were observed to be associated with increased costs. © The ASCRS 2012. Source

The recently released third edition of the International Classification of Sleep Disorders (ICSD) is a fully revised version of the American Academy of Sleep Medicine's manual of sleep disorders nosology, published in cooperation with international sleep societies. It is the key reference work for the diagnosis of sleep disorders. The ICSD-3 is built on the same basic outline as the ICSD-2, identifying seven major categories that include insomnia disorders, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, sleep-related movement disorders, parasomnias, and other sleep disorders. Significant modifications have been made to the nosology of insomnia, narcolepsy, and parasomnias. Major features and changes of the manual are reviewed in this article. The rationales for these changes are also discussed. © 2014 American College of Chest Physicians. Source

Martin B.I.,Dartmouth Hitchcock Medical Center | Deyo R.A.,Oregon Health And Science University | Lurie J.D.,Dartmouth Institute | Carey T.S.,University of North Carolina at Chapel Hill | And 2 more authors.
Spine | Year: 2016

Study Design. An analysis of the State Inpatient Database of North Carolina, 2005 to 2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from nonfederal hospitals. Objective. The aim of the study was to examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications and to forecast the potential impact if the policy were adopted nationally. Summary of Background Data. Few studies have examined the effects of recent changes in commercial coverage policies that restrict the use of lumbar fusion. Methods. We included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. We aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1, 2011. Results. There was a substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100,000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100,000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis, or revision procedures, but there was a coincident increase in decompression without fusion. Conclusion. This commercial insurance policy change had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in spine surgery. Nevertheless, broader adoption of the policy could significantly reduce the national rates of fusion operations and associated costs. © 2016 Wolters Kluwer Health, Inc. Source

Karagas M.R.,One Medical Center Dr | Choi A.L.,Harvard University | Oken E.,Harvard University | Horvat M.,Jozef Stefan Institute | And 5 more authors.
Environmental Health Perspectives | Year: 2012

Background: Methylmercury (MeHg) is a known neurotoxicant. Emerging evidence indicates it may have adverse effects on the neurologic and other body systems at common low levels of exposure. Impacts of MeHg exposure could vary by individual susceptibility or be confounded by beneficial nutrients in fish containing MeHg. Despite its global relevance, synthesis of the available literature on low-level MeHg exposure has been limited. Objectives: We undertook a synthesis of the current knowledge on the human health effects of low-level MeHg exposure to provide a basis for future research efforts, risk assessment, and exposure remediation policies worldwide. Data sources and extraction: We reviewed the published literature for original human epidemiologic research articles that reported a direct biomarker of mercury exposure. To focus on high-quality studies and those specifically on low mercury exposure, we excluded case series, as well as studies of populations with unusually high fish consumption (e.g., the Seychelles), marine mammal consumption (e.g., the Faroe Islands, circumpolar, and other indigenous populations), or consumption of highly contaminated fish (e.g., gold-mining regions in the Amazon). ata synthesis: Recent evidence raises the possibility of effects of low-level MeHg exposure on fetal growth among susceptible subgroups and on infant growth in the first 2 years of life. Low-level effects of MeHg on neurologic outcomes may differ by age, sex, and timing of exposure. No clear pattern has been observed for cardiovascular disease (CVD) risk across populations or for specific CVD end points. For the few studies evaluating immunologic effects associated with MeHg, results have been inconsistent. Conclusions: Studies targeted at identifying potential mechanisms of low-level MeHg effects and characterizing individual susceptibility, sexual dimorphism, and nonlinearity in dose response would help guide future prevention, policy, and regulatory efforts surrounding MeHg exposure. Source

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