Unintended consequences of delisting routine eye exams on retinopathy screening for people with diabetes in Ontario,Canada

Background:

Routine eye examinations for healthy adults aged 20–64 years were delisted from the Ontario Health Insurance Plan in 2004, but they continue to be insured for people with diabetes regardless of age. We sought to assess whether the delisting of routine eye examinations for healthy adults had the unintended consequence of decreasing retinopathy screening for adults with diabetes.

Methods:

We used administrative data to calculate eye examinations for people with diabetes ages 40–64 years and 65 years and older in each 2-year period from 1998 to 2010. We examined differences by sex, income, rurality and type of health care provider. We used segmented linear regression to assess the change in trend before and after 2004.

Results:

For people with diabetes aged 65 years and older, eye examinations rose gradually from 1998 to 2010, with no substantial change between 2004 and 2006. For people with diabetes aged 40–65 years, there was an 8.7% (95% confidence interval [CI] 6.3%–11.1%) decrease in eye examinations between 2004 and 2006. Results were similar for all population subgroups. Ophthalmologic examinations decreased steadily for both age groups during the study period, and there was a decline in optometry examinations for people ages 40–65 years after 2004.

Interpretation:

The delisting of routine eye examinations for healthy adults in Ontario had the unintended consequence of reducing publicly funded retinopathy screening for people with diabetes. More research is needed to understand whether patients are being charged for an insured service or to what degree misunderstanding has prevented patients from seeking care.Diabetic retinopathy is the leading cause of new cases of blindness in people of working age.¹ In the United States, about 40% of adults with diabetes aged 40 years and older have retinopathy, and 8% have vision-threatening retinopathy.² Studies suggest that, if untreated, 50% of patients with proliferative diabetic retinopathy become legally blind within 5 years, compared with only 5% of patients who receive early treatment.³ Regular dilated eye examinations are effective for early detection and monitoring of asymptomatic retinopathy in people with diabetes⁴ and are recommended by clinical practice guidelines.^5,6In Ontario, Canada’s most populous province, medically necessary services are covered by the Ontario Health Insurance Plan (OHIP) for all permanent residents and Canadian citizens living in the province.⁷ Under OHIP, routine eye examinations were fully insured for all children and adults until November 1, 2004. At that time, routine eye examinations ceased being insured for healthy adults aged 20–64 years, but continued to be insured for children aged 19 years and younger and for adults aged 65 years and older.⁸ Regardless of age, adults with diabetes and some other medical conditions affecting the eye, as well as adults receiving social assistance, continued to have an annual eye examination covered by OHIP. Insured examinations are at no cost to the patient and are reimbursed to the provider at about Can$40. In contrast, healthy adults aged 20–64 years are required to pay out-of-pocket or through private insurance for a routine eye examination, with fees set at the discretion of the optometrist⁹ or physician.¹⁰Health policy experts suggest that delisting services from insurance schemes can have unpredictable effects.¹¹ Understanding the effect of delisting on care is particularly important as governments face fiscal pressures and contemplate further reductions in what is publicly insured.¹² We sought to assess whether delisting routine eye examinations for healthy middle-aged adults in Ontario had the unintended consequence of decreasing retinopathy screening for middle-aged adults with diabetes, even though eye examinations continued to be insured for this population.     

Photoperiodic regulation of gametogenesis in a North Atlantic sea star,Asterias vulgaris

Summary

Individuals of the sea star Asterias vulgaris from New Hampshire were maintained under two contrasting regimes of seasonally changing photoperiod. In one regime the lights turned on and off in phase with local sunrise and sunset; in the other, the daily photoperiod was kept 6 months out of phase with ambient photo- period. When dissected after being maintained for 18 months, the gametogenic condition of the out-of-phase animals was found to be 6 months out of phase with that of the in-phase animals. This experiment demonstrates that photoperiodic regulation of reproduction is important even in marine animals that normally experience marked seasonal changes in sea temperature.     

Individual and Coupled Effects of Echinoderm Extracts and Surface Hydrophobicity on Spore Settlement and Germination in the Brown Alga Hincksia irregularis

Marine substrata possess cues that influence the behavior of fouling organisms. Initial adhesion of fouling algal zoospores to surfaces is also theorized to depend primarily upon interactions between substrata and spore cell bodies and flagellar membranes. In an effort to identify cues and surface characteristics that influence spore settlement and early development, the effects of bioactive echinoderm extracts, surface charge, and surface hydrophobicity were examined individually and in tandem on zoospore settlement and germination in Hincksia irregularis. Experiments utilizing 96-well plastic culture plates confirmed that spore settlement and germination were significantly affected by surface charge and hydrophobicity as well as by echinoderm metabolites, both individually and in tandem. Spore settlement rates in the dark over 30?min were >?400% higher on hydrophobic surfaces than on positively and negatively charged surfaces. Spore germling numbers were >?300% higher on hydrophobic surfaces than on positively and negatively charged surfaces when spores were allowed to settle in the light for 30?min and the settled spores allowed to subsequently germinate for 24?h. Spore germling numbers were consistently >?25% higher on hydrophobic surfaces than on positively and negatively charged surfaces when equal numbers of spores were allowed to completely settle in the light and subsequently germinate for 24?h. H. irregularis germ tube lengths were also significantly longer on positively charged plates than on negatively charged plates. All echinoderm extracts tested had significant effects on germination and settlement at levels below those of estimated ecological concentrations. Short-term (30?min) exposure and subsequent germination experiments indicated that higher concentrations of extracts had rapid toxic effects on algal spores. Synchronous effects of echinoderm extracts and plate charge upon spore settlement varied considerably and did not show a strong dose response relationship. Long-term (24?h) exposure of spores to echinoderm extracts had dosage dependent effects on germination and spore survival. The results of this study indicate that H. irregularis spores possess the capacity for complex responses to their environment, utilizing combined cues of surface charge, surface energy and biochemistry to determine where to settle and germinate. These responses may aid spores in the detection of suitable substrata and conditions for settlement in the marine environment.     

Unconjugated Bilirubin Restricts Oligodendrocyte Differentiation and Axonal Myelination

High levels of serum unconjugated bilirubin (UCB) in newborns are associated with axonal damage and glial reactivity that may contribute to subsequent neurologic injury and encephalopathy (kernicterus). Impairments in myelination and white matter damage were observed at autopsy in kernicteric infants. We have recently reported that UCB reduces oligodendrocyte progenitor cell (OPC) survival in a pure OPC in vitro proliferative culture. Here, we hypothesized that neonatal hyperbilirubinemia may also impair oligodendrocyte (OL) maturation and myelination. We used an experimental model of hyperbilirubinemia that has been shown to mimic the pathophysiological conditions leading to brain dysfunction by unbound (free) UCB. Using primary cultures of OL, we demonstrated that UCB delays cell differentiation by increasing the OPC number and reducing the number of mature OL. This finding was combined with a downregulation of Olig1 mRNA levels and upregulation of Olig2 mRNA levels. Addition of UCB, prior to or during differentiation, impaired OL morphological maturation, extension of processes and cell diameter. Both conditions reduced active guanosine triphosphate (GTP)-bound Rac1 fraction. In myelinating co-cultures of dorsal root ganglia neurons and OL, UCB treatment prior to the onset of myelination decreased oligodendroglial differentiation and the number of myelinating OL, also observed when UCB was added after the onset of myelination. In both circumstances, UCB decreased the number of myelin internodes per OL, as well as the myelin internode length. Our studies demonstrate that increased concentrations of UCB compromise myelinogenesis, thereby elucidating a potential deleterious consequence of elevated UCB.     

Use of Psoralen Monoadducts to Compare The Structure of 16S rRNA in Active and Inactive 30S Ribosomal Subunits

Abstract

E. coli 30S ribosomes in the inactive conformation were irradiated at 390 nm in the presence of 4′ -aminomethyl-4,5′,8-trimethylpsoralen (AMT). This produces monoadducts in which AMT is attached to only one strand of an RNA duplex region. After unbound AMT was removed, some ribosomes were activated and then subjected to 360 nm irradiation; others were reirradiated without activation. Electron microscopic examination of 16S rRNA extracted from these two samples showed covalent rRNA loops indicative of rRNA crosslinks. The general pattern of loops closely matched that seen previously after direct psoralen crosslinking of 30S particles. However, the frequency of occurrence of one major class of loops formed by crosslinks between residues near position 500 and the 3′ end was substantially lower for the activated samples, implying that the structure of the 16S rRNA in active and inactive 30S particles is different.     

Stabilization of the prostate‐specific tumor suppressor NKX3.1 by the oncogenic protein kinase Pim‐1 in prostate cancer cells

Loss of NKX3.1 is an early and consistent event in prostate cancer and is associated with increased proliferation of prostate epithelial cells and poor prognosis. NKX3.1 stability is regulated post‐translationally through phosphorylation at multiple sites by several protein kinases. Here, we report the paradoxical stabilization of the prostate‐specific tumor suppressor NKX3.1 by the oncogenic protein kinase Pim‐1 in prostate cancer cells. Pharmacologic Pim‐1 inhibition using the small molecule inhibitor CX‐6258 decreased steady state levels and half‐life of NKX3.1 protein but mRNA was not affected. This effect was reversed by inhibition of the 26S‐proteasome, demonstrating that Pim‐1 protects NKX3.1 from proteasome‐mediated degradation. Mass spectrometric analyses revealed Thr89, Ser185, Ser186, Ser195, and Ser196 as Pim‐1 phospho‐acceptor sites on NKX3.1. Through mutational analysis, we determined that NKX3.1 phosphorylation at Ser185, Ser186, and within the N‐terminal PEST domain is essential for Pim‐1‐mediated stabilization. Further, we also identified Lys182 as a critical residue for NKX3.1 stabilization by Pim‐1. Pim‐1‐mediated NKX3.1 stabilization may be important in maintaining normal cellular homeostasis in normal prostate epithelial cells, and may maintain basal NKX3.1 protein levels in prostate cancer cells. J. Cell. Biochem. 114: 1050–1057, 2013. © 2012 Wiley Periodicals, Inc.     

Demographic response of tundra small mammals to a snow fencing experiment

Snow cover is a key environmental component for tundra wildlife that will be affected by climate change. Change to the snow cover may affect the population dynamics of high‐latitude small mammals, which are active throughout the winter and reproduce under the snow. We experimentally tested the hypotheses that a deeper snow cover would enhance the densities and winter reproductive rates of small mammals, but that predation by mustelids could be higher in areas of increased small mammal density. We enhanced snow cover by setting out snow fences at three sites in the Canadian Arctic (Bylot Island, Nunavut, and Herschel Island and Komakuk Beach, Yukon) over periods ranging from one to four years. Densities of winter nests were higher where snow depth was increased but spring lemming densities did not increase on the experimental areas. Lemmings probably moved from areas of deep snow, their preferred winter habitat, to summer habitat during snow melt once the advantages associated with deep snow were gone. Our treatment had no effect on signs of reproduction in winter nests, proportion of lactating females in spring, or the proportion of juveniles caught in spring, which suggests that deep snow did not enhance reproduction. Results on predation were inconsistent across sites as predation by weasels was higher on the experimental area at one site but lower at two others and was not higher in areas of winter nest aggregations. Although this experiment provided us with several new insights about the impact of snow cover on the population dynamics of tundra small mammals, it also illustrates the challenges and difficulties associated with large‐scale experiments aimed at manipulating a critical climatic factor.     

Nitrogen dynamics following field application of biochar in a temperate North American maize-based production system

Background and aims

Biochar additions to tropical soils have been shown to reduce N leaching and increase N use efficiency. No studies exist verifying reduced N leaching in field experiments on temperate agricultural soils or identifying the mechanism for N retention.

Methods

Biochar derived from maize stover was applied to a maize cropping system in central New York State at rates of 0, 1, 3, 12, and 30 t?ha^-1 in 2007. Secondary N fertilizer was added at 100, 90, 70, and 50 % of the recommended rate (108 kg N ha^-1). Nitrogen fertilizer enriched with ¹⁵?N was applied in 2009 to the 0 and 12 t?ha^-1 of biochar at 100 and 50 % secondary N application.

Results

Maize yield and plant N uptake did not change with biochar additions (p?>?0.05; n?=?3). Less N (by 82 %; p?<?0.05) was lost after biochar application through leaching only at 100 %?N fertilization. The reason for an observed 140 % greater retention of applied ¹⁵?N in the topsoil may have been the incorporation of added ¹⁵?N into microbial biomass which increased approximately three-fold which warrants further research. The low leaching of applied fertilizer ¹⁵?N (0.42 % of applied N; p?<?0.05) and comparatively high recovery of applied ¹⁵?N in the soil (39 %) after biochar additions after one cropping season may also indicate greater overall N retention through lower gaseous or erosion N losses with biochar.

Conclusions

Addition of biochar to fertile soil in a temperate climate did not improve crop growth or N use efficiency, but increased retention of fertilizer N in the topsoil.