Aging
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Context: Fetuin-A inhibits the insulin receptor in vitro. Higher serum fetuin-A concentrations are associated with type 2 diabetes longitudinally and greater adiposity in cross-sectional analyses. Whether higher fetuin-A concentrations are associated with accumulation of adiposity over time is unknown.

Objective: To determine the association of fetuin-A levels with changes in body composition over 5 yr.

Study Design: Observational cohort study nested in the Health Aging and Body Composition Study.

Predictor: Serum fetuin-A levels.

Outcomes: Visceral adipose tissue (VAT), abdominal sc adipose tissue, and thigh muscle area by computed tomography, and waist circumference and body mass index were measured at baseline and again after 5 yr. Percent change and extreme change (>1.5 SDs) in each measure were calculated.

Results: Over 5 yr, subjects lost body mass in each measure, including 6% decline in VAT. Yet each SD (0.42 g/liter) higher fetuin-A concentration was associated with a 5.5% increase in VAT over 5 yr (95% confidence interval 1.9-9.2%; P = 0.003) in models adjusted for age, sex, race, clinical site, diabetes, physical activity, triglycerides, kidney function, and the baseline VAT score. Similarly, higher fetuin-A concentrations were associated with extreme VAT gain (relative risk 1.70, 95% confidence interval 1.12-2.60, P = 0.01). Fetuin-A concentrations were not statistically significant associated with change in any other measures of body composition (P > 0.20).

Conclusions: Higher fetuin-A concentrations are associated with the accumulation of VAT in well-functioning, community-living older persons. The mechanisms linking fetuin-A, VAT, and insulin resistance remain to be determined.

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Journal of Clinical Endocrinology and Metabolism
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The 100th Conference of the Society for the Advancement of Scandinavian Study (SASS) and the 22nd Conference of the Association for the Advancement of Baltic Studies (AABS): "Region, State, Nation, Community: New Research in Scandinavian and Baltic Studies" taking place April 22 – 24, 2010 in Seattle, Washington.

AABS welcomes papers, panels, and roundtable presentations for the first joint conference of Scandinavian and Baltic Studies in the United States.  The conference aims to highlight and foster academic inquiry that draws comparisons between Scandinavia (Iceland, Denmark, Norway, Sweden, and Finland) and the Baltic states (Estonia, Latvia, and Lithuania).  Papers that examine stateless peoples and those left outside of the Scandinavian/Baltic approach, but sharing the same geographic space, are equally welcome.  Papers and panels devoted to individual states are also welcome.  Contributions are encouraged from disciplines including (but not limited to): anthropology, architecture, communication, cultural studies, demography, economics, education, environment, ethnic relations, film studies, fine arts, gender studies, geography, history, international relations, law, linguistics, literature, memory, political science, psychology, public health, religion, sociology, tourism, and advancing Baltic and Scandinavian studies.  Presentations are not to exceed 20 minutes in length.
 
Proposals from Ph.D. students will be considered for a Presidents’ Panel on Scandinavian and Baltic Studies that recognizes the most accomplished and innovative work of new scholars.
 
Paper and panel proposals must include an abstract (no more than 250 words) and a one to two-page curriculum vitae.  Send this material embedded in the body of an e-mail (no attachments) to Aldis Purs at (aldisp@u.washington.edu) by December 11, 2009.  Paper submissions can be mailed to:
 
22nd AABS Conference Chair
University of Washington,
Box 353420
Seattle, WA 98195-3420
 
Conference Website: http://depts.washington.edu/aabs/
Date: April 22-24, 2010
Location:  Crowne Plaza Hotel, 1113 Sixth Ave., Seattle, Washington 98101
 
Registration information will be available on the website.  All presenters must be SASS or AABS members in good standing.   If you are in need of assistance in finding potential co-panelists from either Scandinavian studies or Baltic Studies, please contact the conference organizer (listed above) to help with such networking by November 1, 2009.

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Background and objectives. Rates of dialysis withdrawal are higher among the elderly and lower among Blacks, yet it is unknown whether preferences for withdrawal and engagement in advance care planning also vary by age and race or ethnicity.

Design, setting, participants and methods. We recruited 61 participants from two dialysis clinics to complete questionnaires regarding dialysis withdrawal preferences in five different health states. Engagement in advance care planning (end-of-life discussions), completion of advance directives and ‘do not resuscitate' or ‘do not intubate' (DNR/DNI) orders were ascertained by a questionnaire and from dialysis unit records.

Results. The mean age was 62 ± 15 years; 38% were Black, 11% were Latino, 34% were White and 16% of participants were Asian. Blacks were less likely to prefer dialysis withdrawal as compared with Whites (odds ratio 0.16, 95% confidence interval 0.03-0.88) and other race/ethnicity groups, and this difference was not explained by age, education, comorbidity and other confounders. In contrast, older age was not associated with preferences for withdrawal. Rates of engagement in end-of-life discussions were higher than for documentation of advance care planning for all age and most race/ethnicity groups. Although younger participants and minorities were generally less likely to document treatment preferences as compared with older patients and Whites, they were not less likely to engage in end-of-life discussions.

Conclusions. Preferences for withdrawal vary by race/ ethnicity, whereas the pattern of engagement in advance care planning varies by age and race/ethnicity. Knowledge of these differences may be useful for improving communication about end-of-life preferences and in implementing effective advance care planning strategies among diverse haemodialysis patients.

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Nephrology Dialysis Transplantation
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Mary K. Goldstein

Shorenstein APARC
Stanford University
Encina Hall, Room E-301
Stanford, CA 94305-6055

(650) 736-0771 (650) 723-6530
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2011 AHPP/CEAS Visiting Scholar
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JD, PhD

Dr. Brian Chen is currently a visiting scholar with the Asia Health Policy Program and Center for East Asian Studies at Stanford University. He was recently Shorenstein Asia-Pacific Research Center's 2009-2010 postdoctoral fellow in Comparative Health Policy. As a visiting scholar, Dr. Chen will conduct collaborative research about health of the elderly and chronic disease in China.

As an applied economist, Chen’s research focuses on the impact of incentives in health care organizations on provider and patient behavior. For his dissertation, Chen empirically examined how vertical integration and prohibition against self-referrals affected physician prescribing behavior. His job market paper was selected for presentation at the American Law and Economics Association’s Annual Meeting, the Academy of Management, the Canadian Law and Economics Association, the Conference on Empirical Legal Studies, and the First Annual Conference on Empirical Health Law and Policy at Georgetown Law Center in 2009.  The paper was also nominated for best paper based on a dissertation at the Academy of Management.

Chen comes to the Shorenstein Asia-Pacific Research Center not only with a multidisciplinary law and economics background, but also with an international perspective from having lived and worked in Taiwan, Japan, and France. He has a particularly intimate knowledge of the Taiwanese health care system from his experience as an assistant to the hospital administrator at a medical college in Taiwan.

During his past residence as a postdoctoral fellow with the Asia Health Policy Program, Chen conducted empirical research on cost containment policies in Taiwan and Japan and how those policies impacted provider behavior. His work also contributed to the program’s research activities on comparative health systems and health service delivery in the Asia-Pacific, a theme that encompasses the historical evolution of health policies; the role of the private sector and public-private partnerships; payment incentives and their impact on patients and providers; organizational innovation, contracting, and soft budget constraints; and chronic disease management and service coordination for aging populations.

Dr. Brian Chen recently completed his Ph.D. in Business Administration in the Business and Public Policy Group at the Haas School of Business, University of California at Berkeley. He received a Juris Doctor from Stanford Law School in 1997, and graduated summa cum laude from Harvard College in 1992.

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BACKGROUND: Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors.

METHODS: We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993-1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income.

RESULTS: Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec).

CONCLUSIONS: The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.

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BMC Health Services Research
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Olga Saynina
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Karen Eggleston
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"The Role of the Private Sector in Health" was the topic of a full day symposium held July 11th at the Beijing International Convention Center. Convened one day before the World Congress of the International Health Economics Association, the private sector symposium attracted over a hundred participants from nations around the world. Aiming to foster dialogue between researchers interested in the private sector and policymakers, the event is one in a series with the long-term goal of promoting greater research interest and knowledge generation regarding the private sector to benefit health systems development. The program featured several scientific paper presentations and panels as well as keynote addresses by representatives from the Chinese Ministry of Health and the World Bank.

Karen Eggleston of the Asia Health Policy Program worked alongside several others on the organizing committee for this ongoing collaboration about the role of the private sector in health policy. Other committee members included Ruth Berg, PSP ONE, Abt Associates; Peter Berman, World Bank; Birger Forsberg, Karolinska Institutet; Gina Lagomarsino, Results for Development; Qingyue Meng, Shandong University; Dominic Montagu, University of California, San Francisco; Sara Bennett, Alliance for Health Systems and Policy Research; and Stefan Nachuk, Rockefeller Foundation.

Selected papers about the private health sector in Asia presented at the symposium will appear in the Asia Health Policy Program's working paper series on health and demographic change in the Asia-Pacific.

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Young Kyung Do
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East and Southeast Asia are aging rapidly. South Korea, for example, has become one of the fastest aging societies in the world. In France, 115 years (1865–1980) were required for the proportion of population aged 65 and over to rise from 7 percent to 14 percent, but in South Korea, it is expected that a comparable change will occur in only eighteen years (2000–2018). More strikingly, it will take only eight years (2018–2026) for the proportion of South Korea’s elderly to increase from 14 percent to 20 percent. The nation’s old-age dependency ratio grew from 5.7 percent in 1970 to 12.6 percent in 2005, and is projected to further increase to 72.0 percent by 2050. At the macroeconomic level, these figures suggest an increasing burden on the working-age population to support the elderly population.

Such figures, however, do not tell the whole story about the burden shouldered by the working-age population. The lives of elderly and working-age individuals are not separate but rather, are linked by the institution of the family. Working-age adult children often take on the role of caring for elderly parents, who may have functional limitations and cognitive impairments. Such informal family caregiving is embedded in traditional Korean culture, as it is in many Asian societies that uphold traditional norms of filial piety.

As the elderly population grows, the demand for elderly long-term care will increase sharply. The supply of informal care, however, is decreasing for a number of reasons. Declining fertility rates have already diminished the potential pool of family caregivers. Further reducing the availability of family caregivers is an array of socioeconomic changes, such as increased migration, decreasing rates of intergenerational co-residence, and increasing labor force participation rates among women, who have historically served as the main family caregivers. Adult children, therefore, will increasingly experience a conflict between parental care responsibilities and their own work. Anecdotal evidence suggests that many daughters or daughters-in-law give up their professional employment to care for their disabled parent(s) or parent(s)-in-law. The work-family conflict also has important implications for the economy—informal caregiving may have additional negative effects on the labor force participation of the already shrinking working-age population.

I recently conducted a study using data from the Korean Longitudinal Study of Aging. My study indicated that providing at least ten hours of care per week reduces the probability of female labor force participation by 15.2 percentage points. I concluded that informal care is already an important economic issue in South Korea even though its population aging is still at an early stage. If the current trend continues, the labor market costs of informal caregiving will increase as the country experiences the full force of the demographic transition. One of the expected benefits of the public long-term care insurance implemented in July 2008 is to help family caregivers participate more easily in the labor force. In Japan, there is some evidence that long-term care insurance positively affects female labor force participation, but such beneficial effects have not yet materialized clearly in Korea. In both countries, there is much to learn from early experience with long-term care insurance.

In most parts of Asia, informal caregivers remain invisible on the policy agenda, not only because of cultural norms that perpetuate family-centered care but also because informal care incurs no public cost. However, the demographic transition, coupled with socioeconomic changes in the region, underscores the need to examine whether informal care is really without costs, at both individual and societal levels. Throughout Asia, the challenge for public policy will be finding the optimal mix of informal, family-based and formal, socially supported elder care.

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Abstract: This talk discusses the evolution of nuclear deterrence in the post-Cold War and Post-911 environment.  An examination of the historic role of deterrence and past trends in stockpile composition are discussed, and the concept of a capability-based deterrent and the implications for stockpile size, the nuclear weapons complex, and science are examined.  The role of both complex- and stockpile-transformation in enabling a capability-based deterrent is evaluated

Dr. Martz has been with Los Alamos National Laboratory for 25 years.  He is an authority on plutonium chemistry and metallurgy, and has lead various elements of the nuclear weapons program at Los Alamos including the group responsible for pit activities, the program examining materials aging in the stockpile, leadership of the weapon design division, and most recently, was head of the New Mexico team in the recent Reliable Replacement Warhead Design study.

If you would like to be added to the email announcement list, please visit https://mailman.stanford.edu/mailman/listinfo/stsseminar 

Reuben W. Hills Conference Room

Joseph Martz Senior Staff, Principal Associate Directorate for Nuclear Weapons Speaker
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