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Presidential primary elections arguably represent the most dynamic campaigns in American politics. Television advertising is a key aspect of strategy that candidates can marshal throughout the campaign. We develop a methodology for measuring the impact of advertising in primary elections that accounts for endogeneity and apply it to the 2000 through 2016 elections. We find that advertisements—both positive and negative—improve the favorability and the vote share of the candidate running the ads. We find that negative advertising is more effective than positive advertising, but that only high polling candidates lose support when attacked.
Healthcare-prescribed opioids are a known contributor to the opioid epidemic. Locally, there was an identified opportunity to improve opioid prescribing practices in cardiac surgical patients. The cardiac surgical team sought to standardise prescribing practices in postoperative patients and reduce opioid prescriptions at discharge. The improvement was undertaken at a large midwestern freestanding children’s hospital with over 400 beds and 120 cardiac surgeries annually. A multidisciplinary team was formed, using the model for Improvement to guide the improvement work. The key improvement interventions included standardised evidence-based prescribing guidelines based patient age and surgical approach, enhanced pain management with non-opioid medications, and integration of prescribing guidelines into the electronic health record. The primary outcome measure was rate of compliance with the prescribing guidelines and secondary measures included morphine equivalent dosing at discharge, opioid-free discharge, and length of stay. A balancing measure of opioid re-prescriptions was tracked. There were 289 patients included in the primary study period (January 2019 through December 2021). Sustainability of key outcomes was tracked though December 2022. The guideline compliance increased from 24% to 100%. The morphine equivalent dosing decreased to 22.5 in 2021 then 0 in 2022, from baseline of 36.25 in 2019. Opioid-free discharges decreased from 8% (2019) to 1.5% (2021) and 0% in 2022. Establishment and compliance with standardised guidelines for post-operative cardiac surgical pain management yielded a reduction in morphine equivalent dosing, an increase opioid-free discharges, and no increase in length of stay or opioid re-prescriptions.
Recent changes to US research funding are having far-reaching consequences that imperil the integrity of science and the provision of care to vulnerable populations. Resisting these changes, the BJPsych Portfolio reaffirms its commitment to publishing mental science and advancing psychiatric knowledge that improves the mental health of one and all.
Previous observational studies suggested that vitamin D may control absorption of iron by inhibition of hepcidin, but the causal relevance of these associations is uncertain. Using placebo-controlled randomization, we assessed the effects of supplementation with vitamin D on biochemical markers of iron status and erythropoiesis in community-dwelling older people living in the United Kingdom (UK). The BEST-D trial, designed to establish the optimum dose of vitamin D3 for future trials, had 305 participants, aged 65 years or older, randomly allocated to 4000 IU vitamin D3 (n=102), 2000 IU vitamin D3 (n=102), or matching placebo (n=101). We estimated the effect of vitamin D allocation on plasma levels of hepcidin, soluble transferrin receptor (sTfR), ferritin, iron, transferrin, saturated transferrin (TSAT%), and the sTfR-ferritin index. Despite increases in 25-hydroxy-vitamin D, neither dose had significant effects on biochemical markers of iron status or erythropoiesis. Geometric mean concentrations were similar in vitamin D3 arms vs placebo for hepcidin (20.7 [SE 0.90] vs 20.5 [1.21] ng/mL), sTfR (0.69 [0.010] vs 0.70 [0.015] µg/mL), ferritin (97.1 [2.81] vs 97.8 [4.10] µg/L) and sTfR-ferritin ratio (0.36 [0.006] vs 0.36 [0.009]), respectively, while arithmetic mean levels were similar for iron (16.7 [0.38] vs 17.3 [0.54] µmol/L), transferrin (2.56 [0.014] vs 2.60 [0.021] g/dL), and TSAT% (26.5 [0.60] vs 27.5 [0.85]). The proportions of participants with ferritin <15 µg/L and TSAT<16% were unaltered by vitamin D3 suggesting that 12 months of daily supplementation with moderately high doses of vitamin D3 are unlikely to alter the iron status of older adults.
Specimens of Tulaneia amabilia Runnegar and Horodyski n. gen n. sp. (previously Ernietta plateauensis Pflug) discovered by RJH in 1991 at a site in the Montgomery Mountains near Johnnie, Nevada, are described for the first time. All of the material from the original locality was from float, but its stratigraphic position within the lowest siliciclastic to dolostone interval of the lower member of the Wood Canyon Formation (LMWCF) was confirmed by subsequent discoveries. Because the upper part of the LMWCF contains Treptichnus pedum (Seilacher), the Ediacaran–Cambrian boundary has long been drawn at its first appearance. However, in the Esmeralda Member of the Deep Spring Formation in the White-Inyo Mountains, California, and at Mount Dunfee, Nevada, another Cambrian ichnofossil, ‘Plagiogmus’, which is now Psammichnites gigas arcuatus (Roedel), is found just beneath the nadir of the basal Cambrian isotope excursion (BACE). Because the nadir of the BACE excursion is older than ca. 539 Ma in Mexico, the oldest occurrences of Treptichnus pedum in the LMWCF are latest—not earliest—Fortunian in age, and there is no need to reduce the age of the eon boundary from ca. 539 to ca. 533 Ma. Tulaneia resembles Ernietta and other erniettomorphs in being composed of tubular modules with planar common surfaces, but its overall shape was tabular and unidirectional rather than sack or frond shaped. We also illustrate and briefly describe other trace and body fossils from the LMWCF and re-illustrate previously published specimens of Psammichnites gigas arcuatus in order to document its earliest occurrence in the Great Basin.
An important component of post-release monitoring of biological control of invasive plants is the tracking of species interactions. During post-release monitoring following the initial releases of the weevil Ceutorhynchus scrobicollis Nerenscheimer and Wagner (Coleoptera: Curculionidae) on garlic mustard, Alliaria petiolata (Marschall von Bieberstein) Cavara and Grande (Brassicaceae), in Ontario, Canada, we identified the presence of larvae of the tumbling flower beetle, Mordellina ancilla Leconte (Coleoptera: Mordellidae), in garlic mustard stems. This study documents the life history of M. ancilla on garlic mustard to assess for potential interactions between M. ancilla and C. scrobicollis as a biological control agent. Garlic mustard stems were sampled at eight sites across southern Ontario and throughout the course of one year to record the prevalence of this association and to observe its life cycle on the plant. We found M. ancilla to be a widespread stem-borer of late second–year and dead garlic mustard plants across sampling locations. This is the first host record for M. ancilla on garlic mustard. The observed life cycle of M. ancilla indicates that it is unlikely to negatively impact the growth and reproduction of garlic mustard and that it is unlikely to affect the use of C. scrobicollis as a biological control agent.
Due to the rising occupancy of the radio spectrum, new strategies for covering the ever increasing amount of data are necessary. This work presents a system for integrating data transmission into a frequency-modulated continuous wave (FMCW) radar by modulating the radar signal with frequency shift keying (FSK). The system offers a high chirp bandwidth of 5 GHz and uses the 60 GHz band. The FSK carrier frequency affects the noise level. A higher frequency leads to a lower noise floor due to 1/f-noise but requires a higher sampling rate. Therefore, 15 MHz was chosen as a compromise. A high data rate allows for a fast data transmission but requires a short chirp time, which leads to a noisier frequency chirp. The radar parameters are also affected by this choice. This leads to a baud rate of 20.8 kbit/s. With a higher order FSK, higher data rates are possible. This proves that the data transmission via FMCW radar signals is possible and a first choice if lower data rates are sufficient, because the hardware effort is comparatively low.
With models and research designs ever increasing in complexity, the foundational question of model identification is more important than ever. The determination of whether or not a model can be fit at all or fit to some particular data set is the essence of model identification. In this article, we pull from previously published work on data-independent model identification applicable to a broad set of structural equation models, and extend it further to include extremely flexible exogenous covariate effects and also to include data-dependent empirical model identification. For illustrative purposes, we apply this model identification solution to several small examples for which the answer is already known, including a real data example from the National Longitudinal Survey of Youth; however, the method applies similarly to models that are far from simple to comprehend. The solution is implemented in the open-source OpenMx package in R.
Cognitive behavioural therapists and practitioners often feel uncertain about how to treat post-traumatic stress disorder (PTSD) following rape and sexual assault. There are many myths and rumours about what you should and should not do. All too frequently, this uncertainty results in therapists avoiding doing trauma-focused work with these clients. Whilst understandable, this means that the survivor continues to re-experience the rape as flashbacks and/or nightmares. This article outlines an evidence-based cognitive behavioural therapy (CBT) approach to treating PTSD following a rape in adulthood. It aims to be a practical, ‘how to’ guide for therapists, drawing on the authors’ decades of experience in this area. We have included film links to demonstrate how to undertake each step of the treatment pathway. Our aim is for CBT practitioners to feel more confident in delivering effective trauma-focused therapy to this client group. We consider how to assess and formulate PTSD following a rape in adulthood, then how to deliver cognitive therapy for PTSD (CT-PTSD; Ehlers and Clark, 2000). We will cover both client and therapist factors when working with memories of rape, as well as legal, social, cultural and interpersonal considerations.
Key learning aims
To understand the importance of providing effective, trauma-focused therapy for survivors of rape in adulthood who are experiencing symptoms of PTSD.
To be able to assess, formulate and treat PTSD following a rape in adulthood.
How to manage the dissociation common in this client group.
To be able to select and choose appropriate cognitive, behavioural and imagery techniques to help with feelings of shame, responsibility, anger, disgust, contamination and mistrust.
For therapists to learn how best to support their own ability to cope with working in a trauma-focused way with survivors of rape and sexual violence.
Experimental double-auction commodity markets are known to exhibit robust convergence to competitive equilibria under stable or cyclical supply and demand conditions, but little is known about their performance in truly random environments. We provide a comprehensive study of double auctions in a stochastic setting where the equilibrium prices, trading volumes and gains from trade are highly variable across periods, and with commodity traders who may buy or sell their goods depending on market conditions and their individual outcomes. We find that performance in this stochastic environment is sensitive to underlying market conditions. Efficiency is higher and convergence to the competitive equilibrium stronger when the potential gains from trade are high and when the equilibrium spans a wide range of quantities, implying a large number of marginal trades. Speculative re-trading is prevalent, especially among those who have little to gain under equilibrium pricing. Those with the largest expected gains typically earn far less than predicted, while those with little or no predicted earnings gain modestly from speculation, leading to some redistribution of gains from high to low expected earners. Excessive trading volumes are associated with negative efficiencies in markets with low gains from trade, but not in the high-gains markets, where zero-sum trading and re-trading appear to enforce efficiency and near-equilibrium pricing. Buyers earn more relative to their competitive equilibrium benchmark than sellers do. Introducing trader specialization leads to fewer trading errors and higher market efficiency, but it does not eliminate zero-sum trading and re-trading.
The success of clinical research studies depends on effective recruitment and retention of study participants, yet only a small fraction of patients engage in research studies, even in academic health systems. Increasing awareness of research opportunities and facilitating connections with clinical research study teams would help to improve the success of research programs. In this Special Communications, we describe the creation and evolution of and tools used for the My Research Partners Concierge Service (MRPcs) of an academic health system. The MRPcs provides a centralized point of contact or hub for patients and community members, as well as clinical research organizations and academic partners, who have research-related questions or interests. The MRPcs helps to connect the users of the service with relevant research study teams, personnel, or resources to facilitate their engagement in a clinical research program. Our experience with the MRPcs informs our recommendation that peer institutions organize similar research service hubs for their clinical research programs to help increase awareness of and participation in clinical research by the public and to help increase the success of research programs at fulfilling their ultimate goal of improving the health of their population.
Much has been written about the general justifications for providing legal protection for trade marks — for example, it has been said that trade marks help to reduce consumer search costs, that they protect against the misappropriation of other traders’ labour and investment, and that they may provide traders with incentives to invest in the development of new marks. However, it is important not to conflate these justifications with the reasons for having registered trade mark systems. To the extent that this issue has been considered, the principal justification for registration that has been put forward is that trade mark registers act as an important source of public information. More specifically, trade mark registers provide information as to the signs that are protected in a given commercial sphere and as to matters such as initial ownership of trade marks and subsequent assignments thereof. Consequently, in order for a trade mark register to perform its function effectively, it is essential that it reflect as accurately as possible the marks that enjoy legal protection and that those consulting the register are able to rely on the information it conveys.
Vaccines have revolutionised the field of medicine, eradicating and controlling many diseases. Recent pandemic vaccine successes have highlighted the accelerated pace of vaccine development and deployment. Leveraging this momentum, attention has shifted to cancer vaccines and personalised cancer vaccines, aimed at targeting individual tumour-specific abnormalities. The UK, now regarded for its vaccine capabilities, is an ideal nation for pioneering cancer vaccine trials. This article convened experts to share insights and approaches to navigate the challenges of cancer vaccine development with personalised or precision cancer vaccines, as well as fixed vaccines. Emphasising partnership and proactive strategies, this article outlines the ambition to harness national and local system capabilities in the UK; to work in collaboration with potential pharmaceutic partners; and to seize the opportunity to deliver the pace for rapid advances in cancer vaccine technology.
Viloxazine ER (extended-release capsules; Qelbree®) is a nonstimulant medication, FDA-approved for ADHD in children (≥6 years) and adults. Efficacy and safety for children and adolescents were evaluated in one phase 2 [NCT02633527]and four phase 3 [NCT03247517, NCT03247556, NCT03247530, and NCT03247543], double-blind (DB), placebo-controlled trials that fed into a long-term, open-label extension (OLE) trial [NCT02736656]. Here we report the findings from this OLE trial.
Methods
Participants completing the DB trials were eligible for the OLE. Viloxazine ER was initiated at 100 mg/day (children) or 200 mg/day (adolescents) and adjusted (if needed) over a 12-week Dose-Optimization Period (up to 400 mg/day [children] or 600 mg/day [adolescents]). Maintenance treatment then continued up to 72 months. Safety assessments included adverse events (AEs), clinical laboratory tests, vital signs, ECG (12-lead), and the Columbia Suicide Severity Rating Scale (C-SSRS). Efficacy assessments included the ADHD Rating Scale, 4th (Phase 2) or 5th (Phase 3) Edition (ADHD-RS-IV/5), and the Clinical Global Impression-Improvement (CGI-I) scale. Efficacy was assessed relative to DB baseline at study visits ˜ 3 months apart. Two response measures, 50% improvement in ADHD-RS-IV/5 Total score and CGI-I score of 1-2, were also evaluated.
Results
1100 individuals (646 children; 454 adolescents; 66.5% male/33.5% female) received treatment. Median (range) exposure to viloxazine ER was 260 (1 to 1896) days. AEs were reported by 57.3% participants, most commonly (≥5%) nasopharyngitis (9.7%), somnolence (9.5%), headache (8.9%) decreased appetite (6.0%), and fatigue (5.7%). AEs were mostly mild or moderate in severity (3.9% reported any severe AE); AEs led to viloxazine ER discontinuation for 8.2%. The mean (SD) changes from DB baseline in ADHD-RS IV/5 Total score were -17.0 (14.18) (viloxazine ER) and -11.2 (13.19) (placebo) at the last DB study visit, 24.3 (11.96) at OLE Month 3, and 22.4 (13.62) at participants’ last OLE study visit. ADHD-RS-IV/5 and CGI-I responder rates each exceeded 65% at all OLE visits following Dose-Optimization.
Conclusions
The safety and efficacy of viloxazine ER were maintained with long-term use in children and adolescents with ADHD. No new safety concerns emerged, and efficacy results suggested potential for continued improvement over that seen during DB treatment.
To compare the incidence of surgical site infection (SSI) between cefazolin 3 g and 2 g surgical prophylaxis in patients weighing ≥120 kg that undergo elective colorectal surgery.
Methods:
A multicenter, retrospective cohort study was performed utilizing a validated database of elective colorectal surgeries in Michigan acute care hospitals. Adults weighing ≥120 kg who received cefazolin and metronidazole for surgical prophylaxis between 7/2012 and 6/2021 were included. The primary outcome was SSI, which was defined as an infection diagnosed within 30 days following the principal operative procedure. Multivariable logistic regression was used to identify variables associated with SSI; the exposure of interest was cefazolin 3 g surgical prophylaxis.
Results:
A total of 581 patients were included; of these, 367 (63.1%) received cefazolin 3 g, while 214 (36.8%) received 2 g. Patients who received cefazolin 3 g had less optimal antibiotic timing (324 [88.3%] vs 200 [93.5%]; P = .043) and a higher receipt of at least 1 of the prophylaxis antibiotics after incision (22 [6%] vs 5 [2.3%]; P = .043). There was no SSI difference between cefazolin 3 g and 2 g cohorts (23 [6.3%] vs 16 [7.5%], P = .574). When accounting for age, smoking status, and surgical duration, cefazolin 3 g was not associated with a reduction in SSI (adjOR, .64; 95%CI, .32–1.29).
Conclusions:
Surgical prophylaxis with cefazolin 3 g, in combination with metronidazole, was not associated with decreased SSI compared to 2 g dosing in obese patients undergoing elective colorectal surgery.
High-cost gene therapies strain the sustainability of healthcare budgets. Despite the potential long-term savings promised by certain gene therapies, realizing these savings faces challenges due to uncertainties regarding the treatment’s durability and a lesser-discussed factor: the true potential for cost offset. Our study aims to assess the cost-offset uncertainty for US Medicaid regarding recently approved gene therapies in hemophilia A and B.
Methods
The analysis used 2018 to 2022 Colorado Department of Health Care Policy & Financing data to determine direct costs of standard of care (factor replacement therapy or emicizumab). Cost-simulation models over five- and ten-year time horizons estimated Colorado Medicaid costs if patients switched to gene therapy (valoctocogene roxaparvovec or etranacogene dezaparvovec) versus maintaining standard of care. Patients were included if aged 18 and over with ICD-10-CM codes D66 (hemophilia A) and D67 (hemophilia B). In the base case, severe hemophilia A was defined as requiring greater than or equal to six yearly factor VIII or emicizumab claims and moderate/severe hemophilia B requiring greater than or equal to four factor IX replacement therapy claims annually.
Results
Annual standard-of-care costs were USD426,000 (SD USD353,000) for hemophilia A and USD546,000 (SD USD542,000) for hemophilia B. Valoctocogene roxaparvovec (hemophilia A) had incremental costs of USD880,000 at five years and −USD481,000 at 10 years. Sensitivity analysis revealed a 23 percent chance of break-even within five years and 48 percent within 10 years. Etranacogene dezaparvovec (hemophilia B) showed incremental costs of USD429,000 at five years and −USD2,490,000 at 10 years. Simulation indicated a 32 percent chance of break-even within five years and 59 percent within 10 years. Varying eligibility (≥4 to ≥15 standard-of-care claims) notably affected break-even; for example, valoctocogene roxaparvovec: 40 percent to 77 percent chance of break-even in 10 years.
Conclusions
Our study highlights significant cost variation in the standard of care of patients eligible for gene therapies, adding to the uncertainty surrounding cost estimation and highlighting the importance of addressing this factor in risk-sharing agreements. The impact of varying eligibility criteria on cost offsets emphasizes the importance of carefully defining eligibility when using real-world data in the context of health technology assessment.
Patients with hematological malignancies are at high risk of infections due to both the disease and the associated treatments. The use of immunoglobulin (Ig) to prevent infections is increasing in this population, but its cost effectiveness is unknown. This trial-based economic evaluation aimed to compare the cost effectiveness of prophylactic Ig with prophylactic antibiotics in patients with hematological malignancies.
Methods
The economic evaluation used individual patient data from the RATIONAL feasibility trial, which randomly assigned 63 adults with chronic lymphocytic leukemia, multiple myeloma, or lymphoma to prophylactic Ig or prophylactic antibiotics. The following two analyses were conducted to estimate the cost effectiveness of the two treatments over the 12-month trial period from the perspective of the Australian health system:
(i) a cost-utility analysis (CUA) to assess the incremental cost per quality-adjusted life-year (QALY) gained using data collected with the EuroQol 5D-5L questionnaire; and
(ii) a cost-effectiveness analysis (CEA) to assess the incremental cost per serious infection prevented (grade ≥3) and per infection prevented (any grade).
Results
The total cost per patient was significantly higher in the Ig arm than in the antibiotic arm (difference AUD29,140 [USD19,000]). There were non-significant differences in health outcomes between the treatment arms: patients treated with Ig had fewer QALYs (difference −0.072) and serious infections (difference −0.26) than those given antibiotics, but more overall infections (difference 0.76). The incremental cost-effectiveness from the CUA indicated that Ig was more costly than antibiotics and associated with fewer QALYs. In the CEA, Ig costed an additional AUD111,262 (USD73,000) per serious infection prevented, but it was more costly than antibiotics and associated with more infections when all infections were included.
Conclusions
These results indicate that, on average, Ig prophylactic treatment may not be cost effective compared with prophylactic antibiotics for the group of patients with hematological malignancies recruited to the RATIONAL feasibility trial. Further research is needed to confirm these findings in a larger population and over the longer term.
The new software package OpenMx 2.0 for structural equation and other statistical modeling is introduced and its features are described. OpenMx is evolving in a modular direction and now allows a mix-and-match computational approach that separates model expectations from fit functions and optimizers. Major backend architectural improvements include a move to swappable open-source optimizers such as the newly written CSOLNP. Entire new methodologies such as item factor analysis and state space modeling have been implemented. New model expectation functions including support for the expression of models in LISREL syntax and a simplified multigroup expectation function are available. Ease-of-use improvements include helper functions to standardize model parameters and compute their Jacobian-based standard errors, access to model components through standard R $ mechanisms, and improved tab completion from within the R Graphical User Interface.
Reconciling registration and use as mechanisms by which rights can be acquired in a trade mark is inherently difficult. The federal Australian registered trade mark system is built around a hybrid of a registration-based and a use-based model of protection. While it is perfectly possible to defend such a dual model, the two means of acquiring trade mark rights rest on very different logics. In the event of a conflict between a registered mark and a mark that has been used for some time the question of which should take precedence is not necessarily capable of being determined a priori. The relationship between registration and use is mediated by a number of provisions of the Trade Marks Act 1995 (Cth). In this article we focus on one such provision, s 58A, a relatively recent addition to the legal landscape.
Through a close analysis of s 58A, focusing on court decisions and decisions of the Trade Marks Office that have applied this provision, we demonstrate that s 58A has the potential to operate in an entirely unsatisfactory manner. We then use problems with s 58A as a vehicle to explore the relationship between use-based and registration-based rights generally, suggesting a new conceptual framework that might serve to guide future discussion of how the relationship between registration and use ought to be mediated.