Search

Objective: Somatic variants in UBA1 cause VEXAS, a recently described, systemic autoinflammatory disease. Research on VEXAS has largely focused on highly symptomatic patients. We sought to determine the prevalence of canonical, VEXAS‐associated somatic variants and their disease penetrance in a diverse, unselected population. Methods: We analyzed clinical‐grade whole genome sequencing data from 245,368 participants in the All of Us Research Program. We compared persons carrying a canonical VEXAS‐associated somatic variant to age, sex, and ancestry matched controls across the domains of diagnoses, medications, and laboratory values. Results: 74 participants were identified who carry one VEXAS‐defining somatic variant, UBA1 c.121A>C, p.Met41Leu. The variant allele fraction ranged from 4.5% to 33%. No other canonical VEXAS‐associated variants were identified. Of the 74 carriers, 62 (84%) were women, 20 (27%) were African American, and 14 (19%) were American Admixed/Latino. There was no statistically significant association between case/control status and any VEXAS‐associated diagnosis code, medication prescription, or laboratory value. Conclusion: We report the largest cohort to date of persons with the VEXAS‐associated p.Met41Leu somatic variant. This cohort differed substantially from reported cohorts of patients with clinical VEXAS, having a higher proportion of persons who were young, female, and of diverse ancestry. Variant allele fractions were lower than reported in clinical VEXAS cohorts, and bioinformatic analysis detected no clinical manifestations of VEXAS. Thus, the UBA1 p.Met41Leu somatic variant displayed incomplete penetrance for VEXAS. Further study is needed to determine the natural history of VEXAS‐associated somatic variants in the predisease phase. [ABSTRACT FROM AUTHOR]

The article discusses how forming partnerships with social media influencers offers a novel strategy for supporting cancer care delivery, with the potential for equitable improving adolescents and young adult (AYA) cancer outcomes. Topics include cancer care delivery needs and prior social media approaches for AYAs with cancer, how forming partnerships with cancer influencers has implications for improving AYA cancer care, and examples of social media approaches for addressing AYA disparities.

Background: Advances in health equity rely on representation of diverse groups in population health research samples. Despite progress in the diversification of research samples, continued expansion to include systematically excluded groups is needed to address health inequities. One such group that is infrequently represented in population health research are adults with intellectual disability. Individuals with intellectual disability experience pervasive health disparities. Representation in population health research is crucial to determine the root causes of inequity, understand the health of diverse populations, and address health disparities. The purpose of this paper was to develop recommendations for researchers to increase the accessibility of university health research and to support the inclusion of adults with intellectual disability as participants in health research. Methods: A comprehensive literature review, consultation with the university ethics review board, and review of United States federal regulations was completed to identify barriers to research participation for individuals with intellectual disability. A collaborative stakeholder working group developed recommendations and products to increase the accessibility of university research for participants with intellectual disability. Results: Eleven key barriers to research participation were identified including gaps in researchers' knowledge, lack of trust, accessibility and communication challenges, and systematic exclusion among others. Together the stakeholder working group compiled seven general recommendations for university health researchers to guide inclusion efforts. Recommendations included: 1) address the knowledge gap, 2) build community partnerships, 3) use plain language, 4) simplify consent and assent processes, 5) establish research capacity to consent, 6) offer universal supports and accommodations, and 7) practice accessible dissemination. In addition, four products were created as part of the stakeholder working group to be shared with researchers to support the inclusion of participants with intellectual disability. 1) Supports I Need Checklist, 2) Plain language glossary of health and research terms, 3) Understanding Consent and Assent in Plain Language, 4) Easy-Read Paper Template. Conclusion: Community members and individuals with intellectual disability want to be included in research and are eager to engage as research participants. It is the responsibility of the researcher to open the door to university health research. The recommendations discussed in this paper could increase accessibility for a broader range of research participants and, in particular, promote the inclusion of individuals with intellectual disability to advance health equity in population health research. [ABSTRACT FROM AUTHOR]

This study used focus group methodology to examine South Asian (SA) American women's conceptualizations of eating disorders (EDs) and body dissatisfaction, and their perspectives regarding cultural influences on these conditions. Using a qualitative descriptive approach, seven focus groups were conducted (N = 54, mean age = 20.11 years, SD = 2.52). Themes (n = 15) were organized according to the amended objectification theory framework. Women described experiences of cultural stressors specifically related to living in the United States, and weight stigma from multiple sources, especially older women (e.g., mothers, relatives, and aunties). Participants also experienced pressures to achieve competing body and appearance ideals ("thin" and "healthy"). In addition, they reported pressures to possess light skin, dark black hair, minimal body hair, and marry young, and noted these pressures negatively impacted their body esteem. Findings indicate that a combination of "traditional" and culturally-influenced factors are important to consider when conceptualizing eating pathology and body image in young SA American women. [ABSTRACT FROM AUTHOR]

Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy. [ABSTRACT FROM AUTHOR]

Background: Ibalizumab-uiyk (ibalizumab) is a first-in-class, long-acting, postattachment HIV-1 inhibitor for adults with multidrug-resistant (MDR) HIV-1 infection. This analysis examines the cost-effectiveness and budget impact of ibalizumab treatment for this difficult-to-treat population in the United States. Methods: A Markov model followed cohorts of adults with MDR HIV-1 infection through two final lines of antiretroviral therapy: ibalizumab + optimized background therapy (OBT) or OBT alone followed by nonsuppressive therapy. Model inputs were based on ibalizumab clinical trial data, market uptake projections, and published literature, with costs in 2019 dollars. The cost-effectiveness analysis assessed costs and health outcomes from a health care sector perspective for individuals receiving ibalizumab + OBT versus OBT alone over a lifetime time horizon. The budget-impact analysis estimated the impact on payer budgets of the introduction of ibalizumab over 3 years for a hypothetical commercial health plan. Results: Compared with individuals receiving OBT alone, individuals receiving ibalizumab + OBT incurred higher costs but lived longer, healthier lives, with an incremental cost of $133,040 per QALY gained. For a hypothetical commercial health plan with 1 million members, the introduction of ibalizumab + OBT was estimated to increase budgets by $217,260, $385,245, and $560,310 ($0.018, $0.032, and $0.047 per member per month) in years 1, 2, and 3, respectively. These results were found to be robust in sensitivity and scenario analyses. Conclusions: Ibalizumab may represent a cost-effective and affordable option to improve health outcomes for individuals with MDR HIV-1 infection. [ABSTRACT FROM AUTHOR]

This research conducts an experiment on individuals' perceptions of natural gas pipeline incidents and the expansion of natural gas pipeline infrastructure in the United States. This work contributes to the literature on natural gas pipeline safety and risk by utilizing Kahneman and Tversky's Prospect Theory. This work is relevant from a public policy perspective because of the recent expansion of the U.S. natural gas pipeline network that has been underway since 2010. It provides policy makers with a better understanding of how the public perceives risks and benefits associated with pipeline expansion. Overall, the study results find that when individuals balanced the benefits and risks of pipeline expansion, a majority of all respondents (53.4 percent) picked safety over monetary gains. Further, a majority of respondents who received at least one treatment were more likely to choose safety and two-thirds of respondents who received a second treatment chose safety over material benefits associated with pipeline expansion. [ABSTRACT FROM AUTHOR]

The book club's leader ask[ed] what Fitzgerald meant when he said there are no second acts in American lives. "He [is] saying that the past is always with us," replies D ’Angelo Barksdale, a middle manager in a drug-dealing empire ... "You can say you somebody new. You can give yourself a whole new story. But what came first is who you really are, and what happened before is what really happened."] "The past is whatever the records and the memories agree upon ... [T]he past is whatever the Party chooses to make it. It also follows that though the past is alterable, it never has been altered in any specific instance. For when it has been re-created in whatever shape is needed at the moment, then this new version is the past, and no different past can ever have existed... In Newspeak it is called [D]oublethink." [ABSTRACT FROM AUTHOR]

The article presents an essay anchoring conversations about privacy with a more informed conceptualization of privacy in the U.S. It suggests employing a method for considering how best to accommodate privacy and other very real competing interests in a rational and effective way that gives all competing interests their due.

The article discusses the claim that a lower number of people are pursuing a legal education in America in 2015 as compared to earlier years, and it mentions the costs associated with attending law school, as well as the impacts of declining enrollments on U.S. law schools and the nation's legal community. Student loan debt and post-law school employment problems are examined, along with the perseverance and passion (grit) of those students who do enroll in American law schools.

Objectives: Late age at first birth and nulliparity are established risk factors for breast cancer, yet the extent to which fertility problems contribute to these associations remains largely unexplored. Here, we examine self-reported fertility problems as a risk factor for breast cancer in young women.Methods: We used a population-based case-control study of 2,173 cases and 1,990 controls aged 20 to 54 years in the United States. Structured in-person interviews were used to elicit detailed information on established and potential breast cancer risk factors. Information was collected on pregnancy details, including difficulties becoming pregnant or maintaining a pregnancy.Results: Self-reported difficulty in becoming pregnant or maintaining a pregnancy was reported by 450 cases and 377 controls. Overall, there was little association between these fertility problems and risk of breast cancer (odds ratio [OR] = 1.05). Parity was associated with a decreased risk of breast cancer in women both with (OR = 0.71) and without (OR = 0.79) fertility problems. There was little evidence of an increased risk of breast cancer with later age at first full-term birth among women without fertility problems (ORage 35+ :age <20 = 1.13, 95 percent confidence interval [CI] = 0.7-1.9), but a relatively strong association among women with fertility problems (ORage 35+ :age <20 = 2.96, CI = 1.3-7.0). Among women with a first full-term birth at age 35 or older, fertility problems were associated with a twofold risk of breast cancer. Analyses of duration of unprotected sexual intercourse prior to first pregnancy as an alternative estimate of infertility produced similar results.Conclusions: Our study suggests that the association between late age at first birth and breast cancer is stronger among women with self-reported fertility problems than among women with no fertility problems. [ABSTRACT FROM AUTHOR]

Methodologic investigations have addressed selection and recall bias in case-control studies of diet and breast cancer, whereas the effect of disease progression and medical treatment on estimates of dietary intake has been largely overlooked. In a multicenter, population-based case-control study of breast cancer in the United States, 1,588 newly diagnosed cases and 1,451 controls completed a self-administered food-frequency questionnaire. Initial evaluation suggested increased risk related to high intakes of calories, carbohydrates, fat, and protein. All nutrient associations were diminished after adjustment for calories. Evaluation by stage of disease revealed no relation of calories to risk among women with in situ disease, but elevated risks among women with localized (odds ratio [OR] = 1.33, 95 percent confidence interval [CI] = 1.0-1.7 highest cflowest quartile) or regional and distant disease (OR = 1.79, CI = 1.3-2.4). Further evaluation showed that the increased risk associated with calories was restricted to cases who reported having been treated with chemotherapy (OR = 1.66, CI = 1.3-2.1). A gradient of increasing risk with time interval from diagnosis to interview suggested the chemotherapy regimen itself and not necessarily characteristics of tumors requiring this treatment was responsible for the observed increased risk. These results indicate that epidemiologic studies of diet and breast cancer, particularly among young women, should evaluate possible bias related to post-diagnosis influences. [ABSTRACT FROM AUTHOR]

During the first decades of the 20th century, the very notion and practice of philanthropy changed radically in the United States. American philanthropic foundations moved from caring for those suffering from poverty to reforming society as a whole, guided by their supposed scientific understanding and analysis of social phenomena. What was the impact of this transformation on international institutions like the American School of Classical Studies at Athens?This article focuses on the interest ofAmerican philanthropic foundations in supporting the School's work, and, in particular, on the appropriations of the Carnegie philanthropic trusts from 1904 to 1925. [ABSTRACT FROM AUTHOR]

Quantifying how close hospitals came to exhausting capacity during the outbreak of pandemic influenza A (H1N1) 2009 can help the health care system plan for more virulent pandemics. This ecologic analysis used emergency department (ED) and inpatient data from 34 US children's hospitals. For the 11-week pandemic (H1N1) 2009 period during fall 2009, inpatient occupancy reached 95%, which was lower than the 101% occupancy during the 2008-09 seasonal influenza period. Fewer than 1 additional admission per 10 inpatient beds would have caused hospitals to reach 100% occupancy. Using parameters based on historical precedent, we built 5 models projecting inpatient occupancy, varying the ED visit numbers and admission rate for influenza-related ED visits. The 5 scenarios projected median occupancy as high as 132% of capacity. The pandemic did not exhaust inpatient bed capacity, but a more virulent pandemic has the potential to push children's hospitals past their maximum inpatient capacity. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To estimate the cost-effectiveness of once-daily tenofovir/emtricitabine compared with twice-daily zidovudine/lamivudine and once-daily abacavir/lamivudine in treatment-naïve adults with HIV-1 infection in the United States. Methods: A Markov model with four therapy lines and six health states based on CD4+ cell-count ranges was developed to estimate lifetime costs and health outcomes. Efficacy data (virologic response and CD4+ cell-count changes) for first-line therapy were from 144-week results of Study 934 comparing tenofovir/emtricitabine with zidovudine/lamivudine and 48-week results of Study CNA30024 comparing abacavir/lamivudine with zidovudine/lamivudine, all in combination with efavirenz. Data from Study CNA30024 for abacavir/lamivudine were adjusted to allow for an indirect comparison with tenofovir/emtricitabine. Subsequent therapy lines were based on likely baskets of antiretroviral therapy recommended by US treatment guidelines. Utility values, mortality rates, and costs (2009 US dollars) were obtained from published sources. Base-case results were tested in sensitivity and variability analyses. Results: Average discounted results showed that individuals using tenofovir/emtricitabine were predicted to remain on first-line therapy for 7.7 years, accrue lifetime costs of $747,327, and experience 15.75 quality-adjusted life-years (QALYs), compared with 6.0 years, $777,090, and 15.68 QALYs for individuals using abacavir/lamivudine and 5.8 years, $778,287, and 15.44 QALYs for individuals using zidovudine/lamivudine. Tenofovir/emtricitabine was cost-effective compared with the other two first-line regimens in more than 75% of all probabilistic sensitivity analysis simulation runs for every willingness-to-pay threshold between $0 and $250,000 per QALY gained. Results were robust in variability and one-way sensitivity analyses. Conclusions: Tenofovir/emtricitabine was predicted to be more effective and cost-saving compared with abacavir/lamivudine and zidovudine/lamivudine in treatment-naïve adults with HIV-1 infection in the United States. © 2011, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). All rights reserved. [Copyright &y& Elsevier]

Background: The National Emphysema Treatment Trial (NETT) proved that lung volume reduction surgery (LVRS) was safe and effective in patients with certain clinical characteristics and using defined inclusion-exclusion criteria. Based on the selection criteria developed in that trial, we performed bilateral LVRS on 49 patients during the period of February 2004 until May 2009. Methods: Forty-nine patients underwent lung volume reduction by either median sternotomy (10) or video-assisted thoracoscopic surgery (39) selected according to NETT described parameters. Preoperative characteristics were the following: mean (±SD) age 62.5 ± 6.6 years, preoperative FEV1 (forced expiratory volume in the first second of expiration) 691 cc (± 159), % of predicted FEV1 25.3 (± 6.2), preoperative Dlco (diffusing capacity of lung for carbon monoxide) 7.6 (± 2.7), and % of predicted DLCO 27% (± 7.3). All patients had upper lobe predominant disease and either low exercise capacity (n = 23) or high exercise capacity (n = 26) as defined by the NETT. Results: There was no operative or 90-day mortality. Median length of stay was 8 days (interquartile range = 6 to 10). Two patients required reintubation and tracheostomy but were decannulated prior to discharge. The BODE index (body mass index, airflow obstruction, dyspnea, and exercise capacity), a multidimensional predictor of survival in chronic obstructive pulmonary disease, improved −2.3 (± 1.5, p < 0.0001) (missing data: 5 of 42, 11.9%) and the FEV1 improved 286 cc (± 221, p < 0.0001), both 1 year after surgery. Probability of survival was 0.98 (95% CI [confidence interval] = 0.94 to 1) at 1 year, and 0.95 (95% CI = 0.88 to 1) at 3 years. Conclusions: Surgical lung volume reduction for emphysema can be performed in patients using selection criteria developed by the NETT with very low surgical risk and excellent midterm results. Surgical LVRS is the standard against which other nonsurgical treatments for advanced emphysema should be judged. [Copyright &y& Elsevier]

Objectives: The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. Methods: The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). [ABSTRACT FROM AUTHOR]

Introduction: The phase III TITAN trial evaluated the use of darunavir with low-dose ritonavir (DRV/r) 600/100mg twice daily (bid) compared with lopinavir with low-dose ritonavir (LPV/r) in treatment-experienced, lopinavirnaive patients. This study estimates the cost effectiveness of DRV/r from a US societal perspective when compared with LPV/r in treatment-experienced patients with a profile similar to those TITAN patients who had one or more International AIDS Society - USA (IAS-USA) primary protease inhibitor (PI) resistance-associated mutations (RAMs) at baseline. This population had less advanced HIV disease and a broader range of previous PI exposure/ failure (0-≥2 PIs) at enrolment than those in the darunavir phase IIb POWER trials. Methods: An existing Markov model containing six health states defined by CD4 cell count range (>500, 351-500, 201-350, 101-200, 51-100 and 0-50 cells/mm3) and an absorbing state of death was adapted. Baseline demographics, CD4 cell count distribution and antiretroviral drug usage, virological response (at week 24), and immunological response estimates and matching transition probabilities were based on data collected directly from the one or more IAS-USA PI mutation subpopulation during the first 48 weeks of the TITAN trial, as well as from published literature. Patients were assumed to switch to a regimen containing tipranavir plus an optimized background regimen after treatment failure. For each CD4 cell count range or health state, the utility values, HIV and non-HIV-related mortality rates, and non-antiretroviral-related cost of HIV care estimates were derived from published literature. Unit costs were derived from official local sources. A lifetime horizon was taken in the base-case analysis. Results: The base-case analysis predicted discounted quality-adjusted survival gains of 0.493 quality-adjusted life-years (QALYs) for DRV/r compared with LPV/r, resulting in an incremental cost-effectiveness ratio (ICER) of US$23 057 per QALY gained over a lifetime horizon. Probabilistic sensitivity analysis indicated a 0.754 probability of an ICER below the threshold of US$50 000 per QALY gained. DRV/r remained cost effective over all parameter ranges tested in extensive one-way sensitivity analyses and variability analyses, which examined the impact of input parameter uncertainty and changes in model assumptions and treatment patterns, respectively. Shortening the model time horizon had the largest impact on the ICER, reducing it most notably to US$4919 with a 10-year time horizon. Conclusion: From a US societal perspective and based on an analysis of the patients with primary IAS-USA PI RAMs enrolled in the darunavir phase III TITAN trial, a highly active antiretroviral therapy (HAART) regimen containing DRV/ r 600/100mg bid is estimated to be a cost-effective therapy when compared with a HAART regimen containing LPV/r, for the management of treatment-experienced, PI-resistant, HIV-infected adults with a broad range of previous PI use/failure. [ABSTRACT FROM AUTHOR]

Introduction: Darunavir is a new protease inhibitor (PI) that is co-administered with low-dose ritonavir and has demonstrated substantial efficacy in clinical trials of highly treatment-experienced patients when combined with an optimized background regimen (with or without enfuvirtide). This study estimates the cost effectiveness of darunavir with ritonavir (DRV/r) in this population over 5-year and lifetime time horizons in the USA. Methods: AMarkov model was used to follow a treatment-experienced HIV-1 cohort through six health states, based on CD4 cell count: greater than 500, 351-500, 201-350, 101-200, 51-100 and 0-50 cells/mm³, and death. The magnitude of the CD4 cell count increase and duration of increasing and stable periodswere derived from week 48 DRV/r clinical trial results (POWER 1 and 2). The treatment pathway assumed one regimen switch following treatment failure on the initial regimen. The use of antiretroviral drugs was based on usage in DRV/r clinical trials. US daily wholesale acquisition costs were calculated using the recommended daily doses. For each CD4 cell count range, utility values, HIV-1-related mortality rates and costs for medical resources (other than antiretroviral drug costs) were obtained from published literature. Non-HIV-1-related mortality rates were calculated by applying a relative risk value to the US general population age and gender-specific mortality rates. Costs and outcomes were discounted at 3% per year. One-way and probabilistic sensitivity analyses and variability analysis were performed. Results: In a 5-year analysis, patients receiving DRV/r experienced 3.80 quality-adjusted life-years (QALYs) and incurred total medical costs of US$217 288, while those receiving control PIs experienced 3.60 QALYs and incurred costs of US$218 962. DRV/r was both more effective and less costly than control PIs. For the lifetime analysis, the QALYs and lifetime medical costs with DRV/r were 10.03 and US$565 358, compared with 8.76 and US$527 287 with control PIs. The incremental cost-effectiveness ratio for DRV/r compared with control PIs was US$30 046. One-way sensitivity analyses for both time horizons indicated that the results were most sensitive to changes in the rate of CD4 cell count change during stable and declining periods (lifetime only), duration of stable period (5-year only) and HIV-1-related mortality rates. The results of the variability analysis were most sensitive to the model time horizon. Nevertheless, for all ranges and scenarios tested in these analyses, the incremental cost per QALY gained remained below US$50 000. The probabilistic sensitivity analysis showed that there was a 0.921 and 0.950 probability of a cost-effectiveness ratio below US$50000 per QALY for the 5-year and lifetime time horizon, respectively. Conclusions: DRV/r is predicted to be cost effective compared with control PI in highly treatment-experienced patients and is predicted to yield an average of 0.20 additional QALYs per treatment-experienced patient over 5 years and 1.27 additional QALYs over a lifetime in this population. [ABSTRACT FROM AUTHOR]

Purpose: A comprehensive study comparing the costs and efficacies of darunavir/ritonavir 800/100 mg qd and the other ritonavir-boosted (/r) protease inhibitors (PIs) recommended for treatment-naïve individuals with HIV-1 infection would help health care decision makers identify the value of each boosted PI. Methods: A cost-efficacy model was developed to compare the five recommended boosted PIs, each used with a tenofovir-based nucleotide/nucleoside reverse transcriptase inhibitor backbone. Efficacy was measured by virologic response (ie, HIV-1 ribonucleic acid < 50 copies/mL) at 48 weeks, based on a systematic review and meta-analysis of recent clinical trials. One-year antiretroviral therapy costs and 48-week efficacy values were used to generate the efficiency frontier and cost-efficacy ratios. Results: Darunavir/r was the most efficacious boosted PI, with an incremental cost-efficacy ratio of $27,390 per additional individual with virologic response, compared with fosamprenavir/r. All other regimens were dominated. Darunavir/r combination therapy also had one of the lowest average costs ($26,287) per individual with virologic response, resulting in a maximal number of individuals successfully treated within a fixed budget. The model results were robust in variability and sensitivity analyses. Conclusion: Darunavir/r 800/100 mg qd combination therapy represents a cost-efficacious option for treatment-naïve individuals with HIV-1 infection in the United States. [ABSTRACT FROM AUTHOR]

Introduction: The phase III TITAN trial evaluated the use of darunavir with low-dose ritonavir (DRV/r) 600/100mg twice daily (bid) compared with lopinavir with low-dose ritonavir (LPV/r) in treatment-experienced, lopinavirnaive patients. This study estimates the cost effectiveness of DRV/r from a US societal perspective when compared with LPV/r in treatment-experienced patients with a profile similar to those TITAN patients who had one or more International AIDS Society - USA (IAS-USA) primary protease inhibitor (PI) resistance-associated mutations (RAMs) at baseline. This population had less advanced HIV disease and a broader range of previous PI exposure/ failure (0-≥2 PIs) at enrolment than those in the darunavir phase IIb POWER trials. Methods: An existing Markov model containing six health states defined by CD4 cell count range (>500, 351-500, 201-350, 101-200, 51-100 and 0-50 cells/mm³) and an absorbing state of death was adapted. Baseline demographics, CD4 cell count distribution and antiretroviral drug usage, virological response (at week 24), and immunological response estimates and matching transition probabilities were based on data collected directly from the one or more IAS-USA PI mutation subpopulation during the first 48 weeks of the TITAN trial, as well as from published literature. Patients were assumed to switch to a regimen containing tipranavir plus an optimized background regimen after treatment failure. For each CD4 cell count range or health state, the utility values, HIV and non-HIV-related mortality rates, and non-antiretroviral-related cost of HIV care estimates were derived from published literature. Unit costs were derived from official local sources. A lifetime horizon was taken in the base-case analysis. Results: The base-case analysis predicted discounted quality-adjusted survival gains of 0.493 quality-adjusted life-years (QALYs) for DRV/r compared with LPV/r, resulting in an incremental cost-effectiveness ratio (ICER) of US$23 057 per QALY gained over a lifetime horizon. Probabilistic sensitivity analysis indicated a 0.754 probability of an ICER below the threshold of US$50 000 per QALY gained. DRV/r remained cost effective over all parameter ranges tested in extensive one-way sensitivity analyses and variability analyses, which examined the impact of input parameter uncertainty and changes in model assumptions and treatment patterns, respectively. Shortening the model time horizon had the largest impact on the ICER, reducing it most notably to US$4919 with a 10-year time horizon. Conclusion: From a US societal perspective and based on an analysis of the patients with primary IAS-USA PI RAMs enrolled in the darunavir phase III TITAN trial, a highly active antiretroviral therapy (HAART) regimen containingDRV/ r 600/100mg bid is estimated to be a cost-effective therapy when compared with a HAART regimen containing LPV/r, for the management of treatment-experienced, PI-resistant, HIV-infected adults with a broad range of previous PI use/failure. [ABSTRACT FROM AUTHOR]

The article discusses situations wherein subcontracting necessaries suppliers can assert maritime liens to recover payment for their services. It reveals the effects of the 2008 financial crisis on the shipping industry including the collapse in dry bulk and container shipping, the decline in container shipping market and the reduction in the demand for overseas transportation. It cites shipping companies that were affected by the crisis including Atlas Shipping, Industrial Carriers Inc. and Armada (Singapore) Pte. Ltd. It indicates the approaches used by the U.S. Court of Appeals for the Ninth, Eleventh and Fifth Circuits to deal with contractor and Middleman cases.

There is not a general consensus among scholars about whether public campaign funding initiatives increase electoral competitiveness. U.S. focused research has found the effects of Clean Election (CE) funding present mixed outcomes (Mayer and Wood 1995; GAO 2003; Mayer, Werner, and Williams 2004; Werner and Mayer 2007) On the one hand, research has found that Clean Election funding creates more competitive elections (Bardwell 2002; Mayer, Werner, and Williams 2004). While on the other, Clean Election funding scholars have found that public funding of state legislative candidates has not caused elections to become more competitive (Mayer and Wood 1995; GAO 2003). One reason for the difference in the research literature is likely a result of the program being in its early years of implementation in the U.S. This paper provides a new technique for estimating the short-term and long-range effects of the program by experimenting on the New Jersey case which is designed to cope with limited data. It accomplishes this by creating simulated elections that are based on the lessons-learned in Arizona and Maine, as well as on structural constraints present in New Jersey. The experiment's results confirm the impact of Clean Elections is mixed: The impact of Clean Election funding increases intra-party competition but does not increase inter-party competition. Nevertheless, while the impact of Clean Elections does show some encouraging signs for proponents of electoral reform, it is unlikely to transform the electoral landscape by making elections more competitive. [ABSTRACT FROM AUTHOR]

The purpose of this quantitative study was to examine the relationship between learning preferences of East Asian and American higher education students. A review of the literature revealed a body of qualitative studies suggesting a stereotypical perception of an Asian learning preference influenced by cultural variables and the historical roots of Confucianism. The pedagogical implications of this stereotypical perception are obvious to faculty engaged in teaching and learning with Asian international students in America or abroad. The authors surveyed 233 higher education students from Hong Kong and America using the VARK Questionnaire. The authors used a two-way contingency table analysis and chi-square statistical tests to conduct their cross-cultural comparison on their variables of interest including age, gender, and country. [ABSTRACT FROM AUTHOR]

The article discusses a court case wherein the plaintiff, a state agency, claims to be an arm of the Commonwealth of Puerto Rico for the purpose of invoking sovereign immunity. The U.S. Court of Appeals for the District of Columbia examines the rules concerning the evaluation whether a state agency is an arm of the state for the purpose of qualifying for sovereign immunity using the three-factor test. The court asserts that the agency is an arm of the Commonwealth of Puerto Rico.

Purpose. The cost-effectiveness of treating influenzalike illness (ILI) with oseltamivir in the United States was assessed. Methods. A decision-analysis model was developed with a one-year time horizon to assess the cost-effectiveness of oseltamivir compared with usual care from societal and payer perspectives for four patient populations: high-risk adults, healthy adults, elderly adults, and children. The model used efficacy data from oseltamivir clinical trials and other published literature and assumed oseltamivir was effective only in individuals infected with influenza virus not resistant to oseltamivir and treated within 48 hours of symptom onset. Direct medical costs were based on resources used; indirect costs were estimated based on time lost from work due to illness and premature mortality. Base-case estimates were tested in one-way sensitivity and variability analyses. Results. From a societal perspective, oseltamivir was cost-effective across all populations modeled, with an incremental cost per quality-adjusted life-year gained of $5,388, $6,317, $7,652, and $16,176 for high-risk adults, children, elderly adults, and healthy adults, respectively. Results were similar from a payer perspective. When indirect costs were included (for all populations except elderly adults), oseltamivir was cost saving. In sensitivity analyses, oseltamivir remained cost-effective across all patient populations for all values tested, except the probability of developing influenza-related pneumonia. Variability analyses showed that oseltamivir remained cost-effective under most scenarios tested. Conclusion. Base-case results and sensitivity analyses from a decision-analysis model found that treatment of ILI with oseltamivir was cost-effective compared with usual care from U.S. payer and societal perspectives in all patient populations studied when only direct costs were considered. [ABSTRACT FROM AUTHOR]

Recent use of oral contraceptive pills is associated with a modest risk of breast cancer among very young women. In this US population-based case-control study, we evaluated whether the excess risk associated with recent oral contraceptive use is ubiquitous for all pill types or attributable to specific oral contraceptive preparations. Hormonal content and potency of combination oral contraceptives used for the longest duration within 5 years of interview for breast cancer cases aged 20-44 years (N=1640) were compared with age-matched community controls (N=1492). Women who recently used oral contraceptives containing more than 35 microg of ethinyl oestradiol per pill were at higher risk of breast cancer than users of lower dose preparations when compared to never users (respective relative risks of 1.99 and 1.27, P(trend)<0.01). This relationship was more marked among women <35 years of age, where risks associated with high- and low-dose ethinyl oestradiol use were 3.62 and 1.91 (P(trend)<0.01), respectively. We also found significant trends of increasing breast cancer risk for pills with higher progestin and oestrogen potencies (P(trend)<0.05), which were most pronounced among women aged <35 years of age (P(trend)<0.01). Risk was similar across recently used progestin types. Our findings suggest that newer low-potency/low oestrogen dose oral contraceptives may impart a lower risk of breast cancer than that associated with earlier high-potency/high-dose preparations. [ABSTRACT FROM AUTHOR]

Biologic evidence suggests that the hormones activated by stress affect gestational length, but the results of epidemiologic investigations are inconsistent. The authors of this paper know of no threshold models that have been studied; these models assume that stress does not affect preterm delivery until a certain amount of stress has been experienced but that each unit of stress above the threshold adds to the risk of preterm delivery. By using standard logistic regression, the authors compared threshold and nonthreshold models of the relation between number of stressful life events and preterm delivery in 11 US states. They used data on 1990–1995 births from the Pregnancy Risk Assessment Monitoring System. The risk of preterm delivery among multiparas who gave birth in 1990–1993 increased 7% for each event over five they experienced, but no relation was found for 1994–1995 births. Among primiparas who gave birth in 1994–1995, the risk increased 5% for each event over two, but no relation was found for 1990–1993 births. These results suggest that a threshold model may fit the relation between stress and preterm delivery better than one with no threshold. However, the inconsistent results are difficult to reconcile with a biologic threshold in the relation between stress and preterm delivery. [ABSTRACT FROM PUBLISHER]

Explores the relation of race to restless sleep complaints in older patients undergoing chronic renal dialysis in the United States. Univariate associations between restless sleep complaints and independent variables; Increased risk for restless sleep among persons using sleep or nerve medications.

The article presents an obituary for U.S. clinician Nicholas Gonzalez.

Focuses on different aspects of the United States Tax Equity and Fiscal Responsibility Act of 1982. Rules relating to pensions, completed contracts, safe-harbor leasing and taxpayer compliance; Partial liquidations; Distribution of appreciated property in redemption of stock.

Explains how American writers are recuperating their cultural history by using ghosts in their works. Ghosts in Toni Morrison's novel `Beloved' and August Wilson's play `The Piano Lesson'; Function of ghosts in the literary works; Ghosts in writings of other ethnic groups in the United States; Antecedents of ghost stories.

Presents the Women Physicians' Health Study which focused on harassment among women physicians in the United States. Information on gender-based and sexual harassment; Number of women that were selected to participate in the study; Percentage of women that were ineligible to participate; Methodology used; Findings of the study.

Reports on a study evaluating children less than sixteen years of age who had dog bite injuries that resulted in hospitalization or death to determine the typical characteristics of the children, the dogs and the injuries suffered. Indications that severe dog bites in children occur frequently in those younger than five years old and involve the head and the neck.

This article discusses the level of official participation by women members in a professional association such as the American Public Health Association. According to figures published by the U.S. Census Bureau, during the 1950's the percentage of female professional workers dropped from 39.5 percent to 38.4 percent. Similarly the percent growth of female professionals lagged behind that of males even in those occupations traditionally regarded as female, such as elementary and secondary school teachers, librarians and social workers. These trends were reversed between 1960 and 1970 within selected occupational categories. Sexual inequality in the professions is reflected not only in the status discrepancies between men and women but in income differentials as well. The structural processes which control access to status and advancement in the professions include the colleague system of the profession, the sponsor-protege relationship, demands of the specific professions' inner structure and the sex-typing of occupations.

To investigate whether use of electric blankets, one of the largest sources of electromagnetic field exposure in the home, is associated with the risk of female breast cancer, the authors analyzed data from a population-based US case-control study. The 2,199 case patients were under age 55 years and had been newly diagnosed with breast cancer between 1990 and 1992. The 2,009 controls were frequency-matched to cases by 5-year age group and geographic area. There was little or no risk associated with ever having used electric blankets, mattress pads, or heated water beds among women under age 45 years (adjusted odds ratio = 1.01, 95% confidence interval 0.86–1.18) or among women aged ≥45 years (adjusted odds ratio = 1.12, 95% confidence interval 0.87–1.43). There was no substantial variation in risk with duration of use; with whether the appliance was used only to warm the bed or used throughout the night; with menopausal status; or with the cases' hormone receptor status or stage of disease. Potential breast cancer risk factors that were associated with electric blanket use did not substantially confound the associations under investigation. These data do not support the hypothesis that electric blanket use increases breast cancer risk among women under age 55 years. Am J Epidemiol 1998;148:556–63. [ABSTRACT FROM AUTHOR]

To evaluate whether recreational physical activity is associated with breast cancer among young women, the authors analyzed data from a population-based case-control study. Cases (n = 1, 668) were women under age 45 years who had been newly diagnosed with breast cancer between 1990 and 1992 in Atlanta, Georgia, central New Jersey, or Seattle, Washington. Controls (n = 1, 505) were frequency-matched to cases by 5-year age group and geographic area of residence. Breast cancer was not associated with recreational activity in any of the three time periods assessed (highest quartile of activity vs. lowest: age- and center-adjusted odds ratio (OR) = 0.94 (95% confidence interval (Cl) 0.77–1.15) at ages 12–13 years, OR = 1.08 (95% Cl 0.88–1.32) at age 20 years, and OR = 1.18 (95% Cl 0.97–1.44) during the past year), with the average of the three time periods (OR = 1.02, 95% Cl 0.84–1.25), or with daily climbing of at least two flights of stairs (without stopping) during the past year (daily climbing vs. never climbing: OR = 1.03, 95% Cl 0.86–1.23). Estimates were not modified or confounded by body mass index, menopausal status, or caloric intake during the past year. These results do not support a protective role for physical activity in the risk of breast cancer among young women. Am J Epidemiol 1998; 147: 273–80. [ABSTRACT FROM AUTHOR]

Examines the sources of sex discrimination in educational systems in the U.S. Variables in the definition of discrimination; Inequalities in educational attainment; Emphasis on the six internal psychological-cognitive structures.

The article presents an examination of the arguments raised by U.S. historian, Charles Austin Beard concerning the U.S. Constitution. It also incorporates the economic materialism and consciousness of class in the U.S. political thought. The suggestion that the Constitution had been a successful attempt to restrain excessive democracy, that it had been a triumph for property, especially personality, for what was to be called business and then big business, seemed blasphemy to many and an act of near treason in the dangerous crisis through which American political faith and practice were passing. If U.S. historian Charles Austin Beard was a Marxist, it was only in the sense that he believed those transformations in the structure of society which themselves condition the relations of social classes and the various manifestations of social life must be traced in the last instance to economic causes. To Beard it was important to point out that a great many people who opposed the Constitution were neither fools nor knaves, and that if there were fools among those who supported the Constitution, there were also a number of knaves.