Tennessee's failed managed care program for mental health and substance abuse services

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.     

Temporal processing of the pitch of complex tones

The effect of tone duration on fundamental frequency (F0) discrimination is greater for complexes containing unresolved harmonics than for those containing resolved harmonics [Plack and Carlyon, J. Acoust. Soc. Am. 98, 1355-1364 (1995)]. Three experiments explored this effect further. The first experiment measured sensitivity (as d') to fundamental frequency (F0) differences for two complexes, both with an F0 of 250 Hz. The first complex was low-pass filtered at 1875 Hz to create a resolved complex and the second was bandpass filtered between 5500 and 7500 Hz to create an unresolved complex. The harmonics for the resolved complex were selected so that no two harmonics were the same between the two observation intervals. Performance for both complexes was measured for tone durations of 20, 40, 80, and 160 ms. For the unresolved complex, the effect of duration was greater than that for the resolved complex and greater than the predictions of a "multiple-looks" model assuming either peripheral (before sampling) or central (after combining samples) sources of variance. The second experiment replicated these results using an F0 of 62.5 Hz with the cutoff frequencies of the bandpass filters divided by four, confirming that the effect is related to resolvability and not to spectral region. In the final experiment, F0 discrimination for pairs of complexes separated by a temporal gap was measured relative to that for one complex. Performance for the resolved and unresolved complexes was similar: Very little effect of gap duration was observed and the results were consistent with the predictions of the peripheral-variance multiple-looks model. Taken together, the results suggest that the pitch mechanism for resolved harmonics uses a relatively short sampling window of around 20 ms, while the mechanism for unresolved harmonics may use a more complex strategy for optimizing the combination of information over time, perhaps involving a flexible integration time.     

Evolution of the trappin multigene family in the Suidae

The purpose of the study was to examine the effects of manipulating lung volume (LV) on phonatory and articulatory kinematic behavior during sentence production in healthy adults. Five men and five women repeated the sentence "I sell a sapapple again" under five LV conditions. These included (1) speaking normally, (2) speaking after exhaling most of the air from the lungs, (3) speaking at end expiratory level (EEL), (4) speaking after a maximal inhalation, and (5) speaking after a maximal inhalation while attempting to maintain as normal a mode of speech as possible. From a multichannel recording, measures were made of LV, sound pressure level (SPL), fundamental frequency (F0) and semitone standard deviation (STSD), and upper and lower lip displacements and peak velocities. When compared with the reference condition, the sentence was spoken significantly more quickly at the lowest LV. SPL increased significantly for the high LV condition, as did the women's F0 and STSD. Upper lip displacements and peak velocities generally decreased for LVs other than the reference condition. Lower lip movements showed inconsistent changes as a function of LV. Adjustments to the LV for speech led to SPL and F0 changes consistent with a coordinated control of the respiratory system and the larynx. However, less consistent effects were observed in the articulatory kinematic measures, possibly because of a less direct biomechanical and neural control linkage between respiratory and articulatory structures.     

Model selection for covariance structures analysis in nursing research

Covariance structures analysis is often used in nursing research to appraise statistical models reflecting complex human health processes. The model selection approach in covariance structures analysis is designed to select the "best" model from a specified set of theoretically defensible, competing alternatives, all of which are viewed as approximations. Model selection criteria explicitly incorporate both model misfit in the population and sampling error to evaluate the set of models. The result is that interpretability of model parameters and goodness-of-fit are enhanced simultaneously. Relative merits of the model selection approach are identified in light of technical concerns, parsimony, and use of scientific theory in nursing.     

Spinal neurilemmomas and neurofibromas: central dot sign in postgadolinium MRI

The MR studies of three histologically proven spinal neurilemmomas and neurofibromas were reviewed retrospectively. There were two benign neurilemmomas (schwannomas) and one neurofibroma. The common characteristic of these cases was a central low intensity focus ("dot") seen on postcontrast T1-weighted imaging. The low intensity foci corresponded histologically to a congeries of changes including edema, microcysts, foam cells, hyalinization of blood vessels, old hemorrhage, and dystrophic calcification.     

Transition layer thickness in microlaminar deposits

A theoretical analysis was carried out on the change of composition of a deposit obtained by the dual pulse method of forming laminar metal foils, with transition from a low current to a high current pulse, both in the galvanostatic and the potentiostatic mode of deposition. It was shown that the existence of a transition layer of varying composition between a layer of pure metal 1 and a layer consisting predominantly of the metal 2 is an inherent consequence of the electrochemical process, primarily because of an induction period in the concentration polarization with respect to ions of metal 1. The importance of this transition layer increases as the thickness of the layers of the two metals decreases. Eventually this limits the possibility of obtaining a sharp boundary between the layers, when the nanometre region of layer thickness is reached. Equations are given for calculating the deposition current density and rate of stirring of the electrolyte which provide a deposit of a required level of metal 1 in the layer of metal 2, as well as a required sharpness of the boundary between two layers. Experimental proof of the correctness of the analysis was sought. It was found that significant changes in the properties of the deposit occur in the same range of layer thickness in which the transition of the composition takes places.Nomenclature _c,1, a_c,2 transfer coefficient of the cathodic processes - C interfacial capacitance - C₁, C₂ concentration of the ions of metals 1 and 2 at the interface r - C ₀ ¹ , C ₀ ² concentration of ions of the metals 1 and 2 in solution - D ₁ diffusion coefficient for the diffusion of ions of the metal 1 - E _r,1,E _r,2 reversible potentials of metals 1 and 2, respectively - F the Faraday constant - J ₀ ¹ ,J ₀ ² exchange current density of the metals 1 and 2, respectively - M ₁,M ₂ atomic weights of the metals 1 and 2, respectively - kinematic viscosity of solution - ₁, ₂ densities of the metals 1 and 2 respectively - rotation speed (r.p.s.) - z number of electrons exchanged in the deposition process This paper is dedicated to Professor Brian E. Conway on the occasion of his 65th birthday, and in recognition of his outstanding contribution to electrochemistry.     

Oxidation of formic acid at a high surface area supported platinum modified by foreign metal adatoms

The anodic oxidation of formic acid was studied on platinum distributed in the form of small particles in a porous substrate modified by metal adatoms deposited at underpotentials. The rate of the reaction was greatly enhanced on the commercial catalyst Powercat 3000 (PC 3000). The hydrogen adsorption and the underpotential deposition of several metals at PC 3000 were shown to be dissimilar to that at smooth polycrystalline Pt. Steady-state and long-term experiments were performed to determine the stability of this electrode.     

Neuropsychological function in adults with attention-deficit hyperactivity disorder

Pacemaker therapy in patients with atrial fibrillation means the best current pacemaker therapy for patients with bradycardias with the aim to avoid the onset of atrial fibrillation and to establish DDD pacing despite of a history of atrial tachyarrhythmias. The newer application of pacing is the suppression of atrial arrhythmias in patients with medical refractory atrial tachyarrhythmias. Patients with slow ventricular rates and permanent atrial fibrillation should receive a VVI-pacemaker, if the bradycardias causes syncope, dizziness or a decrease of their exercise tolerance. In case of chronotropic incompetence the pacemaker should provide rate responsive pacing. Patients with sick sinus syndrome should receive an atrial (AAI) or dual-chamber (DDD) pacemaker, because patients with these in contrast to VVI-pacemakers develop less often atrial fibrillation and subsequent complications such as atrial thromboembolism. A dual-chamber or VDD-pacemaker--the latter connected to a VDD-single-lead--is indicated in patients with advanced AV-block. Atrial fibrillation occurs in 3 to 6% of the patients with no history of arrythmia and is, if pacemakers have no automatic mode switch, an often reason to program the devices to the VVI-pacing mode. Nowadays, most DDD(R)-pacemakers provide an automatic mode switch: During an atrial tachycardia the pacemaker switches to a VVI/VVIR mode and restores the initial DDD(R)-pacing mode with termination of the arrhythmia. In respect to the newer applications, one approach to prevent atrial tachyarrhythmias is permanent atrial pacing. As lower pacing rates of 80 to 90 ppm are usually needed and many patients hardly tolerate these pacing rates, new algorithms are under clinical investigation. Another approach is the simultaneous depolarization of the right and left atrium. Biatrial pacing is performed with one lead in the high right atrium and another lead in the coronary sinus. Another solution is bifocal atrial pacing with leads placed in the high right atrium and in the coronary sinus ostium. One effect of the new pacing techniques is to shorten interatrial conduction times. Therefore, biatrial pacing has become a therapy to prevent atrial arrhythmias deriving from delayed interatrial conduction times. As atrial reentry circuits seem to be important in atrial fibrillation, multisite atrial pacing is also performed in patients with medical refractory paroxysmal atrial fibrillation. Preliminary results suggest a more effective prevention of atrial fibrillation; nevertheless, these techniques should be still restricted to patients enrolled in clinical studies.