Wealth and Divorce.

In the United States, wealthier couples have lower divorce risk. Wealth may stabilize marriage through its material value, especially by easing financial stress, or by providing symbolic resources, especially signaling that couples meet normative financial standards for marriage. We first show that the negative association between wealth and divorce holds net of a rich set of controls. All else being equal, having $40,000 in wealth rather than $0 is associated with as big a decline in average predicted divorce risk as having no nonmarital births versus at least one. Second, we show that the negative association between wealth and divorce risk is steepest at low positive wealth levels. Net of covariates, having $40,000 in wealth rather than $0 is associated with as big a decline in average predicted divorce risk as having $400,000 rather than $40,000. Third, we consider evidence for the symbolic perspective, which emphasizes the stabilizing role of owning visible physical assets, and the material perspective, which suggests unsecured debt heightens divorce risk. Consistent with the symbolic perspective, we find that with net worth held constant, ownership of homes and vehicles is negatively associated with divorce risk. However, more research is needed to fully adjudicate between the symbolic and material perspectives.

A novel assessment model for teaching robot-assisted living donor nephrectomy in abdominal transplant surgery fellowship.

BACKGROUND: An increasing number of transplant centers have adopted robot-assisted living donor nephrectomy. Thus, a transplant fellow assessment tool is needed for promoting operative independence in an objective and safe manner. METHODS: In this pilot study, data was prospectively collected on both fellow performance with focus on technique, efficiency, and communication ("overall RO-SCORE"), and operative steps ("operative steps RO-SCORE"). Robotic user performance metrics were analyzed from the da Vinci Xi system, including fellow percent active control time (ACT) and handoff counts. RESULTS: From July 2020 to February 2021, twenty-one robot-assisted donor nephrectomies were performed. In regression analysis, fellow performance (based on both RO-SCOREs and robot % ACT) was significantly associated with both time and case number, with time-to-independence modelled at 8.4-14.2 months, and case number-to-independence estimated at 15-22 cases. Robot user metrics provided valid objective measures alongside RO-SCOREs. CONCLUSIONS: This pilot study provides an effective assessment tool for promoting operative competency in robot-assisted donor nephrectomy among transplant fellows.

The gender wealth gap in the United States: Trends and explanations.

It is difficult to study the gender wealth gap because wealth is usually measured at the household level, and men and women often live in the same household. I use person-level measures of wealth, attributing to each person the assets and debts owned in their name, to study the gender wealth gap in the United States among working age people. Using the Survey of Income and Program Participation, I find that the existence of the gender wealth gap is primarily explained by the gender income gap. However, although the gender income gap has narrowed, the gender wealth gap has widened from the mid-1990s to the mid-2010s. This widening occurred across the wealth distribution and among almost every subgroup by marital status, education, race, and age. This widening of the gender wealth gap cannot be explained by changes in socioeconomic characteristics but is consistent with the trend of increasing wealth inequality.

Assessment of the Potential for Veverimer Drug-Drug Interactions.

Veverimer is a polymer being developed as a potential treatment of metabolic acidosis in patients with chronic kidney disease. Veverimer selectively binds and removes hydrochloric acid from the gastrointestinal tract, resulting in an increase in serum bicarbonate. Veverimer is not systemically absorbed, so potential drug-drug interactions (DDIs) are limited to effects on the absorption of other oral drugs through binding to veverimer in the gastrointestinal tract or increases in gastric pH caused by veverimer binding to hydrochloric acid. In in vitro binding experiments using a panel of 16 test drugs, no positively charged, neutral, or zwitterionic drugs bound to veverimer. Three negatively charged drugs (furosemide, aspirin, ethacrynic acid) bound to veverimer; however, this binding was reduced or eliminated in the presence of normal physiologic concentrations (100-170 mM) of chloride. Veverimer increased gastric pH in vivo by 1.5-3 pH units. This pH elevation peaked within 1 hour and had returned to baseline after 1.5-3 hours. Omeprazole did not alter the effect of veverimer on gastric pH. The clinical relevance of in vitro binding and the transient increase in gastric pH was evaluated in human DDI studies using two drugs with the most binding to veverimer (furosemide, aspirin) and two additional drugs with pH-dependent solubility effecting absorption (dabigatran, warfarin). None of the four drugs showed clinically meaningful DDI with veverimer in human studies. Based on the physicochemical characteristics of veverimer and results from in vitro and human studies, veverimer is unlikely to have significant DDIs. SIGNIFICANCE STATEMENT: Patients with chronic kidney disease, who are usually on many drugs, are vulnerable to drug-drug interactions (DDIs). The potential for DDIs with veverimer was evaluated based on the known site of action and physicochemical structure of the polymer, which restricts the compound to the gastrointestinal tract. Based on the findings from in vitro and human studies, we conclude that veverimer is unlikely to have clinically significant DDIs.

Delayed access to care and unmet burden of pediatric surgical disease in resource-constrained African countries.

BACKGROUND: The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs). METHODS: We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes. RESULTS: The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases). CONCLUSION: These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need. TYPE OF STUDY: Retrospective study and review article LEVEL OF EVIDENCE: III.

Engaging Caregivers in the Treatment of Youth with Complex Developmental and Mental Health Needs.

Caregivers of youth with coexisting cognitive and mental health problems face difficult treatment decisions for their child and have unique challenges engaging in shared decision-making. Many stakeholders can influence care management decisions, and the child's cognitive impairment often prohibits their inclusion in the shared decision-making process. In-depth interviews and focus groups with 37 caregivers elicited their experiences with care management related to their child's educational, mental health, and other care needs. Four themes that describe the process of engagement were awareness, activation, formulating a strategy, and action. Findings show psychoeducation, and peer-to-peer support could enhance caregivers' awareness of the condition and encourage activation, which would help in navigating complex service sectors. Coordinated services could enhance capabilities for formulating a strategy jointly with multiple providers and stakeholders. Ultimately, this would contribute to shared decision-making around a common treatment goal that hopefully leads to better quality of care in the least restrictive setting.

Early Assessment of Lung Cancer Immunotherapy Response via Circulating Tumor DNA.

Purpose: Decisions to continue or suspend therapy with immune checkpoint inhibitors are commonly guided by tumor dynamics seen on serial imaging. However, immunotherapy responses are uniquely challenging to interpret because tumors often shrink slowly or can appear transiently enlarged due to inflammation. We hypothesized that monitoring tumor cell death in real time by quantifying changes in circulating tumor DNA (ctDNA) levels could enable early assessment of immunotherapy efficacy.Experimental Design: We compared longitudinal changes in ctDNA levels with changes in radiographic tumor size and with survival outcomes in 28 patients with metastatic non-small cell lung cancer (NSCLC) receiving immune checkpoint inhibitor therapy. CtDNA was quantified by determining the allele fraction of cancer-associated somatic mutations in plasma using a multigene next-generation sequencing assay. We defined a ctDNA response as a >50% decrease in mutant allele fraction from baseline, with a second confirmatory measurement.Results: Strong agreement was observed between ctDNA response and radiographic response (Cohen's kappa, 0.753). Median time to initial response among patients who achieved responses in both categories was 24.5 days by ctDNA versus 72.5 days by imaging. Time on treatment was significantly longer for ctDNA responders versus nonresponders (median, 205.5 vs. 69 days; P < 0.001). A ctDNA response was associated with superior progression-free survival [hazard ratio (HR), 0.29; 95% CI, 0.09-0.89; P = 0.03], and superior overall survival (HR, 0.17; 95% CI, 0.05-0.62; P = 0.007).Conclusions: A drop in ctDNA level is an early marker of therapeutic efficacy and predicts prolonged survival in patients treated with immune checkpoint inhibitors for NSCLC. Clin Cancer Res; 24(8); 1872-80. ©2018 AACR.

Impact of health systems strengthening on coverage of maternal health services in Rwanda, 2000-2010: a systematic review.

From 2000 to 2010, Rwanda implemented comprehensive health sector reforms to strengthen the public health system, with the aim of reducing maternal and newborn deaths in line with Millennium Development Goal 5, among many other improvements in national health. Based on a systematic review of the literature, national policy documents and three Demographic & Health Surveys (2000, 2005 and 2010), this paper describes the reforms and the policies they were based on, and provides data on the extent of Rwanda's progress in expanding the coverage of four key women's health services. Progress took place in 2000-2005 and became more rapid after 2006, mostly in rural areas, when the national facility-based childbirth policy, performance-based financing, and community-based health insurance were scaled up. Between 2006 and 2010, the following increases in coverage took place as compared to 2000-2005, particularly in rural areas, where most poor women live: births with skilled attendance (77% increase vs. 26%), institutional delivery (146% increase vs. 8%), and contraceptive prevalence (351% increase vs. 150%). The primary factors in these improvements were increases in the health workforce and their skills, performance-based financing, community-based health insurance, and better leadership and governance. Further research is needed to determine the impact of these changes on health outcomes in women and children.

Primed interference: the cognitive and behavioral costs of an incongruity between chronic and primed motivational orientations.

Research has shown that temporarily primed motivational orientations have essentially the same effects on how people pursue their goals as their chronic orientations. This article shows that, despite the interchangeability of temporary and chronic motivations, primed motivational orientations that are incongruent with chronic orientations create interference, requiring the deployment of cognitive resources and thus undermining performance on subsequent tasks that rely on these resources. Across 6 studies, we primed motivational orientations that were either congruent or incongruent with participants' chronic orientations and then assessed their performance on subsequent tasks that required cognitive resources. Consistent with the primed interference hypothesis, we found that incongruity between temporary and chronic motivational orientations undermined participants' (a) inhibition of incorrect but highly accessible responses, (b) mental arithmetic, (c) analytical reasoning, and (d) resistance to temptation. These results--which were observed following the activation of motivations for promotion or prevention (Studies 1-2 and 5-6), high or low need for belonging (Study 3), and high or low power orientations (Study 4)--illustrate the broad implications of holding incongruent chronic and primed orientations.

Moderator effects of cognitive ability and social support on the relation between race-related stress and quality of life in a community sample of black Americans.

The current study examined the combined moderating effects of cognitive ability and social support on the relation between race-related stress and quality of life in a sample of Black Americans. Participants (N = 323) were administered the Wonderlic Personnel Test (WPT; E. F. Wonderlic Associates, Inc., 1983), the Multidimensional Social Support Scale (MDSS; Winefield, Winefield, & Tiggemann, 1992), the Index of Race-Related Stress-Brief (Utsey, 1999), and the WHOQOL-BREF (The WHO Group, 1998). The findings indicated that cognitive ability and social support, conjointly, moderated the relation between individual and cultural race-related stress and quality of life for Black Americans in the current sample. The paper concludes by discussing the study's findings, limitations, and by offering recommendations for future research related to this area of inquiry.

The role of e-Health in the changng health care environment.

In 2005 health care organizations spent 2.3% of total operating expenses on information technology and are slowly developing the infrastructure necessary to expand e-Health capabilities. E-Health is being recognized as a method to improve the overall health status of the population. It is important to build partnerships among health care providers, local community organizations, and national health care associations to ensure the continued development of e-Health initiatives. This study has managerial implications associated with the strategic application of e-Health systems and policy implications on future resource allocation.

Pain Assessment for the Dementing Elderly (PADE): reliability and validity of a new measure.

OBJECTIVES: To establish the reliability and validity of a measure to assess pain in individuals with advanced dementia. DESIGN: Sixty-five residents of long-term care facilities were assessed using a new rating tool, the Pain Assessment for the Dementing Elderly (PADE), in two separate studies: (1) Residents were assessed simultaneously by two different raters, at Time 1 and 2, to establish interrater reliability, stability, and internal consistency. (2) Validity was established by assessing the correlation between an agitation scale and the PADE; by comparing groups with pain as a significant clinical factor (as assessed by an independent rater) versus not a significant factor, and by assessing individuals receiving versus not receiving psychoactive medications. SETTING: Four different long-term care facilities, three skilled nursing facilities, and a locked dementia assisted-living facility. PARTICIPANTS: Twenty-five residents of long-term care facilities with advanced levels of dementia in Study 1, and 40 residents with similar level of dementia in Study 2; 42% of the total sample were rated as having significant painful conditions. MEASUREMENTS: For Study 1, the PADE was administered; for Study 2, the PADE and the Cohen-Mansfield Agitation Inventory (CMAI) were administered. RESULTS: Reliability coefficients were adequate (interrater = 0.54-0.95; stability = 0.70-0.98; and internal consistency = 0.24-0.88). Validity coefficients were likewise encouraging, with the PADE demonstrating the expected relationship with a measure of agitation. The PADE also differentiated between groups that were independently judged to suffer clinically problematic pain versus those who were not. CONCLUSION: The PADE is a reliable and valid tool to assess pain in dementing elderly residents of long-term care facilities.