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The Choosing Wisely campaign recommends against the routine use of erythrocyte sedimentation rate (ESR) for the assessment of acute undiagnosed inflammation or infection. We examined ESR and C-reactive protein (CRP) ordering practices at a large, freestanding children’s hospital. We found that 80% of ESR orders were placed concurrently with a CRP order. We aimed to reduce the ESR testing rate by 20% within 6 months in both inpatient and emergency department (ED) settings.Applying Lean process improvement principles, we interviewed stakeholders from multiple subspecialties and engaged the institutional laboratory stewardship committee to identify the root causes of ESR ordering and design interventions. We conducted provider education (November 2020) and employed clinical decision support through an order panel in the electronic health record (April 2021). The outcome measures were monthly ESR testing rate per 1000 patient days (inpatient) and per 1000 ED visits, analyzed using statistical process control charts. CRP testing rate was a balancing measure.After intervention implementation, the ESR testing rate decreased from 11.4 to 8.9 tests per 1000 inpatient patient days (22% decrease) and from 49.4 to 29.5 tests per 1000 ED visits (40% decrease). This change has been sustained for >1 year postintervention. Interventions were effective even during the coronavirus disease 2019 pandemic when there was a rise in baseline ED ESR ordering rate. CRP testing rates did not increase after the interventions.Education and clinical decision support were effective in reducing the ESR ordering rate in both inpatient and ED settings.

After significant progress as an immediate result of the euro crisis, the drive to complete Europe's Economic and Monetary Union (EMU) has decelerated. While there is a broad consensus in Europe that EMU needs further development, the exact nature and timing of the reform agenda remains controversial. This paper makes an analytical contribution to the ongoing discussion about the euro area's institutional setup. An in-depth look at the remaining gaps in the euro's architecture, and the trade-offs that repairing them would present, suggests the need for long-run progress along three mutually supportive tracks. The first is more fiscal risk sharing, which will help enhance the credibility of the sovereign 'no-bailout' rule. The second is complementary financial sector reforms to delink sovereigns and banks. And the third is more effective rules to discourage moral hazard. Helpfully, this evolution would ensure that financial markets provide more incentives for fiscal discipline than they do now. Introducing more fiscal union comes with myriad legal, technical, operational, and political problems, however, raising questions well beyond the domain of economics. These difficulties notwithstanding, without decisive progress to foster fiscal risk sharing, EMU will continue to face existential risks. JEL F45 * E61 * F02 * G28 * H77, 1 Overview: Confronting Fundamental Constraints The question of how to complete EMU's architecture remains urgent. (1) The euro area's institutions evolved rapidly under the pressure of crisis--adding conditional lending facilities, [...]

AS the global economy struggles with slow growth, political support for freer international trade has weakened, most notably in advanced economies and especially in the United States. While some resistance [...]

In his Robbins Lectures delivered at the London School of Economics in October 2001, Stanley Fischer distilled lessons from his years on the front lines of financial crisis management at [...]

OBJECTIVE--Obesity induces a program of systemic inflammation that is implicated in the development of many of its clinical sequelae. Hepatic inflammation is a feature of obesity-induced liver disease, and our previous studies demonstrated reduced hepatic steatosis in obese mice deficient in the C-C chemokine receptor 2 (CCR2) that regulates myeloid cell recruitment. This suggests that a myeloid cell population is recruited to the liver in obesity and contributes to nonalcoholic fatty liver disease. RESEARCH DESIGN AND METHODS--We used fluorescence-activated cell sorting to measure hepatic leukocyte populations in genetic and diet forms of murine obesity. We characterized in vivo models that increase and decrease an obesity-regulated CCR2-expressing population of hepatic leukocytes. Finally, using an in vitro co-culture system, we measured the ability of these cells to modulate a hepatocyte program of lipid metabolism. RESULTS--We demonstrate that obesity activates hepatocyte expression of C-C chemokine ligand 2 (CCL2/MCP-1) leading to hepatic recruitment of [CCR2.sup.+] myeloid cells that promote hepatosteatosis. The quantity of these cells correlates with body mass and in obese mice represents the second largest immune cell population in the liver. Hepatic expression of CCL2 increases their recruitment and in the presence of dietary fat induces hepatosteatosis. These cells activate hepatic transcription of genes responsible for fatty acid esteritication and steatosis. CONCLUSIONS--Obesity induces hepatic recruitment of a myeloid cell population that promotes hepatocyte lipid storage. These findings demonstrate that recruitment of myeloid cells to metabolic tissues is a common feature of obesity, not limited to adipose tissue. Diabetes 59:916-925, 2010, Obesity induces hepatic accumulation of triglycerides (TGs) and, in a large proportion of obese individuals, leads to the development of nonalcoholic fatty liver disease (1). Liver TG storage in the [...]

Despite an abundance of cross-sectional, panel, and event studies, there is strikingly little convincing documentation of direct positive impacts of financial opening on the economic welfare levels or growth rates of developing countries. The econometric difficulties are similar to those that bedevil the literature on trade openness and growth though, if anything, they are more severe in the context of international finance. There is also little systematic evidence that financial opening raises welfare indirectly by promoting collateral reforms of economic institutions or policies. At the same time, opening the financial account does appear to raise the frequency and severity of economic crises. Nonetheless, developing countries continue to move in the direction of further financial openness. A plausible explanation is that financial development is a concomitant of successful economic growth, and a growing financial sector in an economy open to trade cannot long be insulated from cross-border financial flows. This survey discusses the policy framework in which financial globalization is most likely to prove beneficial for developing countries. The reforms developing countries need to carry out to make their economies safe for international asset trade are the same reforms they need to carry out to curtail the power of entrenched economic interests and liberate the economy's productive potential. [JEL F36, F43, G15, 024] IMF Staff Papers (2009) 56, 63-111. doi:10.1057/imfsp.2008.32, The years after 2002 produced a surge in net capital flows from richer countries to the developing world. In 2008, the World Bank estimated 2007 net private capital flows into [...]

The interwar period was marked by the end of the classical gold standard regime and new levels of macroeconomic disorder in the world economy. The interwar disorder often is linked to policies inconsistent with the constraint of the openeconomy trilemma--the inability of policymakers simultaneously to pursue a fixed exchange rate, open capital markets, and autonomous monetary policy. The first two objectives were linchpins of the pre-1914 order. As increasingly democratic polities faced pressures to engage in domestic macroeconomic management, however, either currency pegs or freedom of capital movements had to yield. This historical analytic narrative is compelling--with significant ramifications for today's world, if true--but empirically controversial. We apply theory and empirics to the interwar data and find strong support for the logic of the trilemma. Thus, an inability to pursue consistent policies in a rapidly changing political and economic environment appears central to an understanding of the interwar crises, and the same constraints still apply today. [JEL F33, F41, F42, N10], In the present era of globalization, one of the most difficult challenges for governments--and for those who advise them--is to understand the constraints under which policies must be designed in [...]

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The European Monetary Union's (EMU) plan for a single currency was analyzed to better understand international developments in open-economy macroeconomics. The lack of quantitative analysis of the advantages and disadvantages of such an undertaking has led bodies such as the Swedish commission on EMU not to advise early entry in light of existing high unemployment. However, the EMU can aid in creating better international economic relations by promoting fiscal stability and preventing protectionism.

Hemolysis in glucose-6-phosphate dehydrogenase (G6PD) deficiency varies by mutation status and the oxidative stressor. Although classified by percent of enzymatic deficiency, variability in normal G6PD values clouds assessment of hemolysis risk by level. This was a retrospective, single institution, cohort study assessing risk of postexposure medication-induced hemolysis in G6PD deficient patients. Exposures occurred in 87 of 1415 deficient patients. Only 2 of 87 medication-exposed patients had hemolytic episodes and both had very low enzymatic activity. No hemolytic events occurred with G6PD levels >7 units/g hemoglobin. Correlation of levels with mutation may improve predictive capacity for hemolysis in G6PD deficiency.

Mark Twain is reputed to have remarked that history does not repeat itself, but it often rhymes. While the Global Financial Crisis of 2008–2009 was not a catastrophe on the order of World War I, there is a broad similarity in the sequelaeto both of these events—a failed attempt to return to pre-trauma normalcy, followed by a process of international economic disintegration in the face of changed geopolitical realities. In this essay, I explore three questions that this similarity raises. Does globalization inherently foster domestic or international dynamics that eventually lead to political backlash? If so, are these dynamics inevitable, or can complementary economic policies nurture a stable globalization? And finally, since policies are endogenous, when are policy approaches and institutions that complement and support globalization likely to arise?

Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by quantitative and qualitative defects in von Willebrand factor (VWF). The laboratory diagnosis of VWD in pediatric patients is complicated by VWF interassay and intra‐assay variability, stress‐induced elevations in VWF levels, and a lack of significant bleeding history with which to correlate test results.

The article highlights the importance of making connections in a world of constant change. Topics discussed include enabling social capital that contain resources and ideas that can be accessed and mobilized through social networks; and connecting the right people within and across networks. The article also notes a broker's social skills that include generous listening, inventive translation, and polymathic curiosity.

The mechanisms underlying the maintenance of long-lasting humoral immunity are not well understood. Studies in mice indicate that plasma cells (PCs) can survive up to a lifetime, even in the absence of regeneration by B cells, implying the presence of long-lived PCs as a mechanism for long-lasting immunity. Evidence from humans treated with anti-CD20, which depletes circulating B cells, also suggests B-cell–independent long-term survival of some PCs. On the other hand, antibody responses may be sustained solely by short-lived PCs with repopulation from clonally related memory B cells. To explore PC longevity and humoral immunity in humans, we investigated the fate of PCs and their antibodies in adult and pediatric patients who received chimeric antigen receptor–based adoptive T-cell immunotherapy targeting CD19 to treat B-cell lineage malignancies (CTL019). Treatment with CTL019 is frequently associated with B-cell aplasia that can persist for years. Serum antibody titers to vaccine-related antigens were measured, and quantitative assessment of B cells and PCs in blood and bone marrow was performed at various time points before and after CTL019 therapy. While total serum immunoglobulin concentrations decline following CTL019-induced B-cell aplasia, several vaccine/pathogen-specific serum immunoglobulin G and A (IgG and IgA) titers remain relatively stable for at least 6 and 12 months posttreatment, respectively. Analysis of bone marrow biopsies after CTL019 revealed 8 patients with persistence of antibody-secreting PCs at least 25 months post-CTL019 infusion despite absence of CD19+CD20+ B cells. These results provide strong evidence for the existence of memory B-cell–independent, long-lived PCs in humans that contribute to long-lasting humoral immunity.

Sanitation management for grain storage, grain processing and feed manufacturing operations. Storage facilities, machinery, and building construction for good sanitation program.

Selection, operation and maintenance of scales in feed plants and grain elevators. Includes truck and railroad scales.

Energy conservation in feed mill operation can be achieved with good management and some automatic control systems. Cost effectiveness of the systems can be figured with little trouble using a method described in 'Energy Management for the Feed Industry,' a publication by the American Feed Manufacturers Association.

AbstractA key precursor of twentieth-century financial crises in emerging and advanced economies alike was the rapid buildup of leverage. Those emerging economies that avoided leverage booms during the 2000s also were most likely to avoid the worst effects of the twenty-first century's first global crisis. A discrete-choice panel analysis using 1973–2010 data suggests that domestic credit expansion and real currency appreciation have been the most robust and significant predictors of financial crises, regardless of whether a country is emerging or advanced. For emerging economies, however, higher foreign exchange reserves predict a sharply reduced probability of a subsequent crisis. (JEL E44, F34, F44, G01, G21, O19)

AbstractThe rapid growth of international reserves, a development concentrated in the emerging markets, remains a puzzle. In this paper, we suggest that a model based on financial stability and financial openness goes far toward explaining reserve holdings in the modern era of globalized capital markets. The size of domestic financial liabilities that could potentially be converted into foreign currency (M2), financial openness, the ability to access foreign currency through debt markets, and exchange rate policy are all significant predictors of reserve stocks. Our empirical financial-stability model seems to outperform both traditional models and recent explanations based on external short-term debt. (JEL E23, E43, E44, F31, F32, F34)

Provides information on globalization and macroeconomics. Integration of global economy; Discussion on credibility problem of pegged exchange rates; Realms in which capital mobility may threaten national sovereignty.

In recent years, neuroscientists have begun to investigate topics that traditionally have been the preserve of psychoanalysts (e.g., consciousness, unconscious mentation, dreams, affect, drive, psychopathology). The explosion of new insights into numerous problems of vital interest to psychoanalysis has not yet been reconciled and coordinated with existing psychoanalytic knowledge. Similarly, neuroscientists tackling these complex psychological problems for the first time have much to learn from a century of psychoanalytic inquiry.What is needed is a rapprochement between researchers and clinicians belonging to these historically separate disciplines, a time and a place where they can learn about and enhance each other’s perspectives and knowledge on matters of mutual interest.

This study examined the hypotheses that individuals who are sexually functional and/or highly satisfied with their sexual relations exhibit an androgynous gender identity as well as high levels of congruence among their gender identity, sex-role expectations, and sex-role performance. Conversely, it was hypothesized that sexually dysfunctional and/or dissatisfied people display a polarized gender identity and low levels of congruence among their gender identity, sex-role expectations, and sex-role performance. A total of 61 married or intimate heterosexual couples served as subjects. Each subject completed a Bern Sex-Role Inventory three times, the instructions differing each time in order to provide measures of gender identity, sex-role expectations, and sex-role performance. Subjects also completed specially designed questionnaires which gauged their sexual functioning and sexual satisfaction. The results did not support the hypotheses. Instead, the evidence suggested that sexual functioning and satisfaction for both men and women are associated with the perception that the actor possesses significantly more masculine traits than the typical same-sex person, whereas dysfunction-ing and lower levels of satisfaction are associated with the perception that the actor exhibits more feminine traits than the typical member of one's sex group. The implications of these findings are discussed.

This paper develops a dynamic model of seigniorage in which economies' equilibrium paths reflect the ongoing strategic interaction between an optimizing government and a rational public. The model extends existing positive models of monetary policy and inflation by explicitly incorporating the intertemporal linkages among budget deficits, debt, and inflation. A central finding is that the public's rational responses to government policies may well create incentives for the government to reduce inflation and the public debt over time. A sufficiently myopic government may, however, provoke a rising equilibrium path of inflation and public debt.

We propose that analysis of purchasing power parity (PPP) and the law of one price should explicitly take into account the possibility of “commodity points”—thresholds delineating a region of no central tendency among relative prices, possibly due to lack of perfect arbitrage in the presence of transaction costs and uncertainty. More than 80 years ago, Heckscher stressed the importance of such incomplete arbitrage in the empirical application of PPP. We devise an econometric method to identify commodity points. Price adjustment is treated as a nonlinear process, and a threshold autoregression offers a parsimonious specification within which both thresholds and adjustment speeds are estimated by maximum likelihood methods. Our model performs well using post-1980 data, and yields parameter estimates that appear quite reasonable: adjustment outside the thresholds might imply half-lives of price deviations measured in months rather than years, and the thresholds correspond to popular rough estimates as to the order of magnitude of actual transport costs. The estimated commodity points appear to be positively related to objective measures of market segmentation, notably nominal exchange rate volatility.J. Japan Int. Econ.December 1997,11(4), pp. 441–479. Department of Economics, University of California, Berkeley, California 94720-3880; and Department of Economics, Northwestern University, Evanston, Illinois 60208-2600.

Focuses on several aspects of foreign exchange rate targeting. Problem of imperfect government credibility under managed exchange rates; Theory of exchange rate target zones and regime switches under uncertainty; Role of official foreign exchange intervention in pursuit of exchange rate targets.

Doshi: Bayer: Research Funding. Lambert:Rigel: Consultancy; Summus: Consultancy; Shionogi: Consultancy; Novartis: Membership on an entity's Board of Directors or advisory committees; Educational Concepts in Medicine: Consultancy; Bayer: Membership on an entity's Board of Directors or advisory committees; CSL: Consultancy; Sysmex: Consultancy; Amgen: Membership on an entity's Board of Directors or advisory committees.

Lambert: Amgen: Membership on an entity's Board of Directors or advisory committees; Sysmex: Consultancy; Bayer: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Educational Concepts in Medicine: Consultancy; Summus: Consultancy; Rigel: Consultancy; Shionogi: Consultancy; CSL: Consultancy.