Blue Ridge Area Health Education Center

Medicaid expansion in North Carolina has notably improved payer mix, lowered rates of uninsured and charity care, and boosted billable revenue for safety-net organizations such as Federally Qualified Health Centers. At the same time, expansion has added administrative complexities and enrollment difficulties, which produced uneven benefits across the state's FQHC programs.

Humans and nonhuman primates (NHPs) harbor complex gut microbial communities that affect phenotypes and fitness. The gut microbiotas of wild NHPs reflect their hosts' phylogenetic histories and are compositionally distinct from those of humans, but in captivity the endogenous gut microbial lineages of NHPs can be lost or replaced by lineages found in humans. Despite its potential contributions to gastrointestinal dysfunction, this humanization of the gut microbiota has not been investigated systematically across captive NHP species. Here, we show through comparisons of well-sampled wild and captive populations of apes and monkeys that the fraction of the gut microbiota humanized by captivity varies significantly between NHP species but is remarkably reproducible between captive populations of the same NHP species. Conspecific captive populations displayed significantly greater than expected overlap in the sets of bacterial 16S rRNA gene variants that were differentially abundant between captivity and the wild. This overlap was evident even between captive populations residing on different continents but was never observed between heterospecific captive populations. In addition, we developed an approach incorporating human gut microbiota data to rank NHPs' gut microbial clades based on the propensity of their lineages to be lost or replaced in captivity by lineages found in humans. Relatively few microbial genera displayed reproducible degrees of humanization in different captive host species, but most microbial genera were reproducibly humanized or retained from the wild in conspecific pairs of captive populations. These results demonstrate that the gut microbiotas of captive NHPs display predictable, host-species specific responses to captivity.

We denied this request because: The American Geriatrics Society 2012 BEERS criteria suggest that the requested drug is potentially unsafe in people over the age of 65 years. Since the safety of the drug requested has not been proven in people over the age of 65 years, we have not approved this request. The AGS should strongly protest to CIGNA, and other applicable parties involved in Medicare Part D, the misuse of the criteria and should oppose further efforts to apply the BEERS clinical criteria administratively where they are not appropriate. CIGNA appears to have created a computer edit that automatically denies any drug on the Beers list in any patient aged 65 and older. This does not appear to be a pharmacological judgment; it does not take into account many other clinical factors, such as previous use of the medication, other coadministered medications, degree of frailty of the patient, specific indications, alternative medications, or the opinion of the prescriber. There does not appear to be any pharmacist review of this automatic decision; it is not based on any patient-specific factors. They have created a dangerous standard wherein any drug on the Beers list has to be “proven” safe for people aged 65 and older. Very few older or generic drugs have been proven safe in elderly adults because of lack of specific clinical trials, expense, and previous Food and Drug Administration approval policy; most will never be proven safe. Although there may be specific safety risks for frail elderly adults, this is a clinical judgment that only the clinician who is treating the individual can make; a pharmacist cannot and should not make that decision, and a computer program certainly should not. CIGNA has not taken into account the quantitative risks involved. Only the treating physician can weigh the risks against the benefits, and for many of these medications, the potential risks may be minimal compared with the probable benefit. Factors such as dose, comorbid conditions, polypharmacy, physiological age, patient preference, cost, and formulary availability are important factors that should be considered when using the criteria, as was properly pointed out in the discussion of the 2012 Beers criteria. The risks to individuals of having medication denied, especially one that they had been previously taken, is significant. It appears that the insurance company, through their letters to beneficiaries, is implying that the physician is prescribing a dangerous drug to them. In addition, by declining to cover it, it creates a potentially dangerous situation whereby a beneficiary cannot get a prescription filled in a timely fashion. Obtaining approval after an administrative denial creates a major delay through the burdensome and expensive appeals process. These drugs do not require prior authorization. Please protest loudly to Medicare Part D insurers, the Centers for Medicare and Medicaid Services, and the medical and geriatric communities (AARP, for example) that a private corporation is misusing a clinical guideline to deny care. While other insurers make suggestions and provide information to physicians, second-guessing their choice of medications, usually under a pharmacist's supervision, this particular insurer has preemptively overruled a clinical choice that the individual's treating physician has made without knowledge of any of the clinical details. CIGNA has clearly misapplied the Beers criteria in a potentially harmful fashion, and as the developer of the criteria, the AGS should not allow this. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Marc Berger is responsible for the entire content of this paper. Sponsor's Role: None.

The author reviews an article (L. C. Eaves & H. H. Ho, 2004) published in the Journal of Autism and Developmental Disorders that discussed screening tools and diagnostic assessments used to identify autism in 2‐year‐olds as well as a follow‐up study 2½ years later. The author also provides a discussion of the impact of receiving this diagnosis on families and roles for counselors.