Willingness to pay for improved working conditions of nurses: Results from a factorial survey experiment in Germany.

BACKGROUND: Many countries face substantial shortages of skilled nurses. With an aging population and global demographic changes, developing a skilled workforce of nurses has become one of the central challenges for public health care. The recent COVID-19 pandemic has exacerbated labor shortages, which pose a threat to the quality of publicly provided health care. Improving nurses' working conditions could be a means by which to address the global shortages of nurses. However, in countries with public health care, such improvements may come with additional costs in the form of higher taxes or social security contributions. Therefore, such improvements partly depend on people's willingness to pay (WTP) for them. OBJECTIVE: In this paper, we investigate workers' willingness to pay for improvements in the working conditions of nurses. DESIGN: This study is a factorial survey experiment included as part of an online survey. SETTING(S): The factorial survey experiment was implemented within the high-frequency online panel survey "Life and Employment in Times of Corona" (IAB-HOPP) conducted by the Institute for Employment Research (Germany). PARTICIPANTS: We analyze data from N = 2128 survey participants; our main analysis consists of N = 6384 responses from those participants. METHODS: Our research is based on a factorial survey experiment (vignette analysis) designed to quantitatively measure the willingness to pay for various improvements in the working conditions of nurses. We use random effect models and mixed models to estimate the individual-level willingness to pay for these improvements. RESULTS: Our results show that the survey participants are generally willing to pay for particular policies aimed at improving the working conditions of nurses. However, the amount that respondents are willing to pay varies with the type of policy changes. Survey participants exhibit a high willingness to pay for increases in minimum wages for nurses and wage-related improvements in general. We find, however, a lower willingness to pay for the right to participate in training courses aimed at reducing work-related stress. CONCLUSIONS: The broad support for improvements in the working conditions of nurses provides policymakers with some guidance in implementing policy measures that might address labor shortages in the nursing sector. REGISTRATION: There was no preregistration. Tweetable abstract Many people are willing to pay extra to improve the working conditions of nurses. Wage-related increases for nurses show the highest willingness to pay.

Airway obstruction in two children with congenital central hypoventilation syndrome and review of the literature.

Congenital central hypoventilation syndrome (CCHS) is an autosomal dominant disease that is caused by heterozygous mutations in the paired-like homeobox 2B gene (PHOX2B). Madani et al. described an abnormally high degree of not only central apnea but also obstructive and mixed apnea in Phox2b27Ala/+newborn mice. Newborns with CCHS must undergo polysomnography for obstructive respiratory events in order to guide the optimal ventilation strategy if oxygen desaturation, bradycardia, and malaise persist under noninvasive ventilation. Newborns and infants with CCHS must be systematically tested for obstructive apnea, especially in cases of inefficient noninvasive ventilation.

Ecological Stability Emerges at the Level of Strains in the Human Gut Microbiome.

The human gut microbiome harbors substantial ecological diversity at the species level as well as at the strain level within species. In healthy hosts, species abundance fluctuations in the microbiome are thought to be stable, and these fluctuations can be described by macroecological laws. However, it is less clear how strain abundances change over time. An open question is whether individual strains behave like species themselves, exhibiting stability and following the macroecological relationships known to hold at the species level, or whether strains have different dynamics, perhaps due to the relatively close phylogenetic relatedness of cocolonizing lineages. Here, we analyze the daily dynamics of intraspecific genetic variation in the gut microbiomes of four healthy, densely longitudinally sampled hosts. First, we find that the overall genetic diversity of a large majority of species is stationary over time despite short-term fluctuations. Next, we show that fluctuations in abundances in approximately 80% of strains analyzed can be predicted with a stochastic logistic model (SLM), an ecological model of a population experiencing environmental fluctuations around a fixed carrying capacity, which has previously been shown to capture statistical properties of species abundance fluctuations. The success of this model indicates that strain abundances typically fluctuate around a fixed carrying capacity, suggesting that most strains are dynamically stable. Finally, we find that the strain abundances follow several empirical macroecological laws known to hold at the species level. Together, our results suggest that macroecological properties of the human gut microbiome, including its stability, emerge at the level of strains. IMPORTANCE To date, there has been an intense focus on the ecological dynamics of the human gut microbiome at the species level. However, there is considerable genetic diversity within species at the strain level, and these intraspecific differences can have important phenotypic effects on the host, impacting the ability to digest certain foods and metabolize drugs. Thus, to fully understand how the gut microbiome operates in times of health and sickness, its ecological dynamics may need to be quantified at the level of strains. Here, we show that a large majority of strains maintain stable abundances for periods of months to years, exhibiting fluctuations in abundance that can be well described by macroecological laws known to hold at the species level, while a smaller percentage of strains undergo rapid, directional changes in abundance. Overall, our work indicates that strains are an important unit of ecological organization in the human gut microbiome.

Community diversity is associated with intra-species genetic diversity and gene loss in the human gut microbiome.

How the ecological process of community assembly interacts with intra-species diversity and evolutionary change is a longstanding question. Two contrasting hypotheses have been proposed: Diversity Begets Diversity (DBD), in which taxa tend to become more diverse in already diverse communities, and Ecological Controls (EC), in which higher community diversity impedes diversification. Previously, using 16S rRNA gene amplicon data across a range of microbiomes, we showed a generally positive relationship between taxa diversity and community diversity at higher taxonomic levels, consistent with the predictions of DBD (Madi et al., 2020). However, this positive 'diversity slope' plateaus at high levels of community diversity. Here we show that this general pattern holds at much finer genetic resolution, by analyzing intra-species strain and nucleotide variation in static and temporally sampled metagenomes from the human gut microbiome. Consistent with DBD, both intra-species polymorphism and strain number were positively correlated with community Shannon diversity. Shannon diversity is also predictive of increases in polymorphism over time scales up to ~4-6 months, after which the diversity slope flattens and becomes negative - consistent with DBD eventually giving way to EC. Finally, we show that higher community diversity predicts gene loss at a future time point. This observation is broadly consistent with the Black Queen Hypothesis, which posits that genes with functions provided by the community are less likely to be retained in a focal species' genome. Together, our results show that a mixture of DBD, EC, and Black Queen may operate simultaneously in the human gut microbiome, adding to a growing body of evidence that these eco-evolutionary processes are key drivers of biodiversity and ecosystem function.

Pervasive selective sweeps across human gut microbiomes.

The human gut microbiome is composed of a highly diverse consortia of species which are continually evolving within and across hosts. The ability to identify adaptations common to many host gut microbiomes would not only reveal shared selection pressures across hosts, but also key drivers of functional differentiation of the microbiome that may affect community structure and host traits. However, to date there has not been a systematic scan for adaptations that have spread across host microbiomes. Here, we develop a novel selection scan statistic, named the integrated linkage disequilibrium score (iLDS), that can detect the spread of adaptive haplotypes across host microbiomes via migration and horizontal gene transfer. Specifically, iLDS leverages signals of hitchhiking of deleterious variants with the beneficial variant, a common feature of adaptive evolution. We find that iLDS is capable of detecting simulated and known cases of selection, and moreover is robust to potential confounders that can also elevate LD. Application of the statistic to ~20 common commensal gut species from a large cohort of healthy, Western adults reveals pervasive spread of selected alleles across human microbiomes mediated by horizontal gene transfer. Among the candidate selective sweeps recovered by iLDS is an enrichment for genes involved in the metabolism of maltodextrin, a synthetic starch that has recently become a widespread component of Western diets. In summary, we demonstrate that selective sweeps across host microbiomes are a common feature of the evolution of the human gut microbiome.

Malignant peripheral nerve sheath tumor arising in association with the sural nerve.

Malignant peripheral nerve sheath tumor is a rare sarcoma of peripheral nerves found most often in deep soft tissue. This aggressive tumor is difficult to diagnose clinically and must be surgically excised for therapy. An incisional biopsy will allow for testing and in most cases, diagnosis. The authors present a case of a 39-year-old African American woman with malignant peripheral nerve sheath tumor in association with the sural nerve. The tumor was surgically removed and sent for pathologic studies. The patient reported to her first postoperative appointment and was referred to an oncologist for follow-up. Despite multiple attempts at contacting the patient and explaining the prognosis of the diagnosis, the patient refused further follow-up care including referral to an oncologist.