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Health care costs in the United States are much higher than in other countries. These cost differences can be explained in part by a lack of competition in the United States. Some markets, such as pharmaceuticals and medical equipment, have elements of monopoly. Other markets, such as health insurance, have elements of monopsony. Many other markets may be subject to collusion on prices, such as generic drugs, or wages, such as the nurse labor market. Lawful monopoly and monopsony are beyond the reach of antitrust laws, but collusion is not. When appropriate, vigorous antitrust enforcement challenging anticompetitive conduct can aid in reducing health care costs. This book addresses monopoly, monopsony, cartels of sellers and buyers, horizontal and vertical merger policy, and antitrust enforcement through private suits as well as the efforts of the antitrust Agencies. The authors demonstrate how enforcing antitrust laws can ultimately promote competition and reduce health care costs.
The rift setting of eastern Africa preserves exceptional records of mammalian (including hominin) fossils and archeology. The Afar region is host to multiple deposits with sediments ranging in age from>9 Ma to the present (Chorowicz, 2005; Katoh et al., 2016) and plays a major role in our understanding of human origins. The Gona project area contains fossiliferous deposits that span ca. 6.3 to <0.15 Ma (Quade et al., 2008); the duration of this record means that it can make a distinct contribution to understanding the environmental context for human evolution within the Afar and in eastern Africa (Figures 17.1 and 17.2). The primary units at Gona include the late Miocene Adu-Asa Formation, which contains fossils of Ardipithecus kaddaba; the early Pliocene Sagantole Formation with fossils of Ardipithecus ramidus; the mid- to late-Pliocene Hadar Formation; and the Busidima Formation (ca. 2.7 Ma to <0.15 Ma), which contains a record of the earliest Oldowan stone tools, fossils of Homo erectus, and Acheulean artifacts (Figure 17.2).
In vitro maturation of oocytes (IVM) describes a process whereby immature oocytes that have been collected as part of an assisted reproductive treatment cycle are matured in a laboratory. After maturation, they are usually fertilized with sperm, via intracytoplasmic sperm injection (ICSI), and the resulting embryos cultured. The perceived benefits of this technology are that it involves a shorter duration of time between the commencement of a treatment cycle and oocyte collection, and it avoids the risk of ovarian hyperstimulation syndrome (OHSS). OHSS is a very serious medical condition that women with polycystic ovary syndrome (PCOS) are particularly susceptible to developing. IVM technology has been used for several decades, but in the last ten years there has been a resurgence of interest in its use with the development of enhanced maturation media to assist the IVM process and the initiation of several randomized trials to compare potential benefits and drawbacks in comparison to the standard in vitro fertilization (IVF) approach.
The segregation of reactive elements (REs) along thermally grown oxide (TGO) grain boundaries has been associated to slower oxide growth kinetics and improved creep properties. However, the incorporation and diffusion of these elements into the TGO during oxidation of Ni alloys remains an open question. In this work, electron backscatter diffraction in transmission mode (t-EBSD) was used to investigate the microstructure of TGO within the thermal barrier coating on a Ni-based superalloy, and atom probe tomography (APT) was used to quantify the segregation behavior of REs to α-Al2O3 grain boundaries. Integrating the two techniques enables a higher level of site-specific analysis compared to the routine focused ion beam lift-out sample preparation method without t-EBSD. Needle-shaped APT specimens readily meet the thickness criterion for electron diffraction analysis. Transmission EBSD provides an immediate feedback on grain orientation and grain boundary location within the APT specimens to help target grain boundaries in the TGO. Segregation behavior of REs is discussed in terms of the grain boundary character and relative location in TGO.
Animal and human data demonstrate independent relationships between fetal growth, hypothalamic-pituitary-adrenal axis function (HPA-A) and adult cardiometabolic outcomes. While the association between fetal growth and adult cardiometabolic outcomes is well-established, the role of the HPA-A in these relationships is unclear. This study aims to determine whether HPA-A function mediates or moderates this relationship. Approximately 2900 pregnant women were recruited between 1989-1991 in the Raine Study. Detailed anthropometric data was collected at birth (per cent optimal birthweight [POBW]). The Trier Social Stress Test was administered to the offspring (Generation 2; Gen2) at 18 years; HPA-A responses were determined (reactive responders [RR], anticipatory responders [AR] and non-responders [NR]). Cardiometabolic parameters (BMI, systolic BP [sBP] and LDL cholesterol) were measured at 20 years. Regression modelling demonstrated linear associations between POBW and BMI and sBP; quadratic associations were observed for LDL cholesterol. For every 10% increase in POBW, there was a 0.54 unit increase in BMI (standard error [SE] 0.15) and a 0.65 unit decrease in sBP (SE 0.34). The interaction between participant’s fetal growth and HPA-A phenotype was strongest for sBP in young adulthood. Interactions for BMI and LDL-C were non-significant. Decomposition of the total effect revealed no causal evidence of mediation or moderation.
Herbicide-resistant (HR) crops are widely grown throughout the United States and Canada. These crop-trait technologies can enhance weed management and therefore can be an important component of integrated weed management (IWM) programs. Concomitantly, evolution of HR weed populations has become ubiquitous in agricultural areas where HR crops are grown. Nevertheless, crop cultivars with new or combined (stacked) HR traits continue to be developed and commercialized. This review, based on a symposium held at the Western Society of Weed Science annual meeting in 2021, examines the impact of HR crops on HR weed management in the U.S. Great Plains, U.S. Pacific Northwest, and the Canadian Prairies over the past 25 yr and their past and future contributions to IWM. We also provide an industry perspective on the future of HR crop development and the role of HR crops in resistance management. Expanded options for HR traits in both major and minor crops are expected. With proper stewardship, HR crops can reduce herbicide-use intensity and help reduce selection pressure on weed populations. However, their proper deployment in cropping systems must be carefully planned by considering a diverse crop rotation sequence with multiple HR and non-HR crops and maximizing crop competition to effectively manage HR weed populations. Based on past experiences in the cultivation of HR crops and associated herbicide use in the western United States and Canada, HR crops have been important determinants of both the selection and management of HR weeds.
We significantly extend the results of Miles & Sneyd (J. Fluid Mech., vol. 497, 2003, pp. 435–439) for an accelerating line load on a floating ice plate in their simple linear mathematical model by proceeding to numerical calculations for the response due to a decelerating load. Our results show: (i) how the deflections produced by an impulsively started steadily moving line load begin to develop and eventually approach the well-known steady load-speed-dependent quasi-static and wave-like forms, including above the shallow water gravity wave speed where the shadow zone evolves; (ii) the singularity in the deflection predicted in the simple linear model when the load moves steadily is indeed avoided by a uniformly accelerating load, where the magnitude of the deflection continually increases and its maximum lags a little further behind as the load moves through the critical speed and beyond; (iii) there is also no singularity in the deflection due to a uniformly decelerating load, but whereas the response from a subcritical starting speed is preserved and travels with the load, the magnitude of the deflection may become quite large near a load starting from supercritical speed and approaching rest, which is attributed to constructive interference (reinforcement) as erstwhile trailing, predominantly gravity, waves catch up with the load. While this reinforcement poses no risk to Hercules transport aircraft landing on the thick sea ice at McMurdo Sound, it can account for the reported rapid sinking of the detached cockpit shortly after it came to rest in the 1974 Lockheed Electra aircraft crash in the Canadian Arctic.
Medical students are vulnerable to stress and depression during medical school and the COVID-19 pandemic may have exacerbated these issues. This study examined whether the risk of depression was associated with COVID-19 pandemic-related medical school communication.
A 144 - item pilot cross-sectional online survey of medical students in the US, was carried out between September 1, 2020 and December 31, 2020. Items on stress, depression, and communication between students and their medical schools were included. This study examined associations of student perceptions of universities’ communication efforts and pandemic response with risk of developing depression.
The sample included 212 students from 22 US states. Almost 50% (48.6%) were at risk of developing depression. Students felt medical schools transitioned well to online platforms, while the curriculum was just as rigorous as in-person courses. Students at risk of developing depression reported communication was poor more frequently compared to students at average risk. Students at risk of depression were also more than 3 times more likely to report their universities’ communication about scholarships or other funding was poor in adjusted analyses.
Universities communicated well with medical students during the pandemic. However, this study also highlights the need for ongoing efforts to address student mental health by medical schools.
The coronavirus disease 2019 pandemic has greatly disrupted head and neck cancer services in the West of Scotland. This study aimed to assess the impact of the first wave of the pandemic on cancer waiting times.
A retrospective review of multidisciplinary team records was undertaken between March and May in 2019 and the same months in 2020. Time-to-diagnosis and time-to-treatment for new cancers treated with curative intent were compared between the study periods, and subclassified by referral pathway.
A total of 236 new cancer patients were included. During the pandemic, pathways benefitted from reduced diagnostic and treatment times resulting from the restructuring of service provisions. A 75 per cent reduction in secondary care referrals and a 33 per cent increase in urgent suspicion of cancer referrals were observed in 2020.
Head and neck cancer pathway times did not suffer because of the coronavirus pandemic. Innovations introduced to mitigate issues brought about by coronavirus benefitted patients, led to a more streamlined service, and improved diagnostic and treatment target compliance.
Major depressive disorder (MDD) is the leading cause of disability worldwide. Patients with MDD have high rates of comorbidity with mental and physical conditions, one of which is chronic pain. Chronic pain conditions themselves are also associated with significant disability, and the large number of patients with MDD who have chronic pain drives high levels of disability and compounds healthcare burden. The management of depression in patients who also have chronic pain can be particularly challenging due to underlying mechanisms that are common to both conditions, and because many patients with these conditions are already taking multiple medications. For these reasons, healthcare providers may be reluctant to treat such patients. The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines provide evidence-based recommendations for the management of MDD and comorbid psychiatric and medical conditions such as anxiety, substance use disorder, and cardiovascular disease; however, comorbid chronic pain is not addressed. In this article, we provide an overview of the pathophysiological and clinical overlap between depression and chronic pain and review evidence-based pharmacological recommendations in current treatment guidelines for MDD and for chronic pain. Based on clinical experience with MDD patients with comorbid pain, we recommend rapidly and aggressively treating depression according to CANMAT treatment guidelines, using antidepressant medications with analgesic properties, while addressing pain with first-line pharmacotherapy as treatment for depression is optimized. We review options for treating pain symptoms that remain after response to antidepressant treatment is achieved.
First-year cardiology fellows must quickly learn basic competency in echocardiography during fellowship orientation. This educational process was disrupted in 2020 due to the coronavirus pandemic, as our hands-on echocardiography teaching transitioned from practice on paediatric volunteers to simulation-based training. We previously described an improvement in echocardiographic completeness after implementation of a standardised imaging protocol for the performance of acute assessments of ventricular function. Herein, we assessed whether this improvement could be sustained over the two subsequent years, including the fellowship year affected by the pandemic. Echocardiograms performed by first-year paediatric cardiology fellows to assess ventricular function were reviewed for completeness. The frequency with which each requested component was included was measured. A total demographic score (out of 7) and total imaging score (out of 23) were calculated. The pre-protocol years (2015–2017) were compared to the post-protocol years (2018–2020), and the pre-COVID years (2018–2019) were compared to the year affected by COVID (2020). There was a sustained improvement in completeness after protocol implementation with improvement in the demographic score (median increasing from 6 to 7, p < 0.001) and imaging score (median increasing from 13 to 16, p < 0.001). More individual components showed a statistically significant increase in frequency compared to our prior publication. The COVID pandemic resulted in very few differences in completeness. Demographic reporting improved modestly (p = 0.04); the imaging score was unchanged (p = 0.59). The only view obtained less frequently was the apical two-chamber view. A standardised imaging protocol allowed sustained improvements in echocardiographic completeness despite the disruption of fellowship orientation by COVID-19.
Annual balances of eight alpine glaciers were slightly negative for 1961–90 and highly negative for 1991–2018. We explain this by changes in positive degree-day sums and summer temperatures extrapolated to the median altitudes of the glaciers. We test a new way of calculating degree-day sums that performs better than the traditional method which used daily mean temperatures. Annual degree-day sums are highly correlated with May–September temperatures as suggested in 1866 by Karl von Sonklar. We find moderate correlations between annual balances and degree-day sums, and with May–September temperatures. Calculated degree-day factors for the eight glaciers cover the reported range for snow and ice ablation, while the temperature sensitivity of annual balance is from −0.4 to −1.0 m w.e. for a +1°C temperature change. We accurately predict mean balances for 1991–2018 using May–September temperatures in regression models calibrated for 1961–90. May–September temperatures in the Alps have already increased ~+3°C since 1880 and, if temperatures continue to rise, these glaciers will shrink rapidly. As annual balances are already negative for present-day temperatures, these glaciers will not be ‘safe’ under the further temperature increase permitted by the Paris Agreement.
We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim–sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy.
This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis.
Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58–15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07–4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15–1.44) were associated with longer antibiotic duration.
We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.
Health and social care workers (HSCWs) are at risk of experiencing adverse mental health outcomes (e.g. higher levels of anxiety and depression) because of the COVID-19 pandemic. This can have a detrimental effect on quality of care, the national response to the pandemic and its aftermath.
A longitudinal design provided follow-up evidence on the mental health (changes in prevalence of disease over time) of NHS staff working at a remote health board in Scotland during the COVID-19 pandemic, and investigated the determinants of mental health outcomes over time.
A two-wave longitudinal study was conducted from July to September 2020. Participants self-reported levels of depression (Patient Health Questionnaire-9), anxiety (Generalised Anxiety Disorder-7) and mental well-being (Warwick-Edinburgh Mental Well-being Scale) at baseline and 1.5 months later.
The analytic sample of 169 participants, working in community (43%) and hospital (44%) settings, reported substantial levels of depression and anxiety, and low mental well-being at baseline (depression, 30.8%; anxiety, 20.1%; well-being, 31.9%). Although mental health remained mostly constant over time, the proportion of participants meeting the threshold for anxiety increased to 27.2% at follow-up. Multivariable modelling indicated that working with, and disruption because of, COVID-19 were associated with adverse mental health changes over time.
HSCWs working in a remote area with low COVID-19 prevalence reported substantial levels of anxiety and depression, similar to those working in areas with high COVID-19 prevalence. Efforts to support HSCW mental health must remain a priority, and should minimise the adverse effects of working with, and disruption caused by, the COVID-19 pandemic.
Conservation scientists are increasingly recognizing the need to evaluate the effectiveness of interventions to improve human–wildlife coexistence across different contexts. Here we assessed the long-term efficacy of the Long Shields Community Guardians programme in Zimbabwe. This community-based programme seeks to protect livestock and prevent depredation by lions Panthera leo through non-lethal means, with the ultimate aim of promoting human–lion coexistence. Using a quasi-experimental approach, we measured temporal trends in livestock depredation by lions and the prevalence of retaliatory killing of lions by farmers and wildlife managers. Farmers that were part of the Long Shields programme experienced a significant reduction in livestock loss to lions, and the annual number of lions subject to retaliatory killing by farmers dropped by 41% since the start of the programme in 2013, compared to 2008–2012, before the programme was initiated. Our findings demonstrate the Long Shields programme can be a potential model for limiting livestock depredation by lions. More broadly, our study demonstrates the effectiveness of community-based interventions to engage community members, improve livestock protection and ameliorate levels of retaliatory killing, thereby reducing human–lion conflict.
Co-enzyme Q10 (CoQ10), transported in the blood by lipoproteins, is an essential component of the inner mitochondrial membrane and is responsible for electron transport in the mitochondrial respiratory chain for oxidative phosphorylation to generate the energy substrate adenosine triphosphate (ATP), and acts as an anti-oxidant within the oocyte. Observational studies suggest that the follicular fluid concentration of CoQ10 diminishes with age (1), and low CoQ10 antioxidant status may indeed correlate with oocyte aneuploidy (2). Consequently it would appear there is a sound rationale for the use of CoQ10 during infertility treatment, perhaps for women with perceived ‘poor oocyte quality’. Furthermore the scientific rationale is supported by several animal studies which demonstrate a beneficial effect of CoQ10 supplementation on embryonic development. However, before all clinicians are encouraged to prescribe Coq10 as the eternal elixir of reproductive youth, evidence for a benefit of supplementation in the IVF clinical setting is required.
Evidence for risk of dying by suicide and other causes following discharge from in-patient psychiatric care throughout adulthood is sparse.
To estimate risks of all-cause mortality, natural and external-cause deaths, suicide and accidental, alcohol-specific and drug-related deaths in working-age and older adults within a year post-discharge.
Using interlinked general practice, hospital, and mortality records in the Clinical Practice Research Datalink we delineated a cohort of discharged adults in England, 2001–2018. Each patient was matched to up to 20 general population comparator patients. Cumulative incidence (absolute risks) and hazard ratios (relative risks) were estimated separately for ages 18–64 and ≥65 years with additional stratification by gender and practice-level deprivation.
The 1-year cumulative incidence of dying post-discharge was 2.1% among working-age adults (95% CI 2.0–2.3) and 14.1% (95% CI 13.6–14.5) among older adults. Suicide risk was particularly elevated in the first 3 months, with hazard ratios of 191.1 (95% CI 125.0–292.0) among working-age adults and 125.4 (95% CI 52.6–298.9) in older adults. Older patients were vulnerable to dying by natural causes within 3 months post-discharge. Risk of dying by external causes was greater among discharged working-age adults in the least deprived areas. Relative risk of suicide in discharged working-age women relative to their general population peers was double the equivalent male risk elevation.
Recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first 3 months post-discharge.
We performed viral culture of nasopharyngeal specimens in individuals aged 79 and older, infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2), 10 days after symptom onset. A positive viral culture was obtained in 10 (45%) of 22 participants, including 4 (33%) of 12 individuals with improving symptoms. The results of this small study suggest that infectivity may be prolonged among older individuals.
Antimicrobial resistance (AMR) is one of the defining global health threats of our time, but no international legal instrument currently offers the framework and mechanisms needed to address it. Fortunately, the actions needed to address AMR have considerable overlap with the actions needed to confront other pandemic threats.