Objective To examine the association between payments made by the manufacturers of pharmaceuticals to physicians and prescribing by physicians within hospital referral regions.Design Cross sectional analysis of 2013 and 2014 Open Payments and Medicare Part D prescribing data for two classes of commonly prescribed, commonly marketed drugs: oral anticoagulants and non-insulin diabetes drugs, overall and stratified by physician and payment type.Setting 306 hospital referral regions, United States.Participants 45 949 454 Medicare Part D prescriptions written by 623 886 physicians to 10 513 173 patients for two drug classes: oral anticoagulants and non-insulin diabetes drugs.Main outcome measures Proportion, or market share, of marketed oral anticoagulants and non-insulin diabetes drugs prescribed by physicians among all drugs in each class and within hospital referral regions.Results Among 306 hospital referral regions, there were 977 407 payments to physicians totaling $61 026 140 (£46 174 600; €54 632 500) related to oral anticoagulants, and 1 787 884 payments totaling $108 417 616 related to non-insulin diabetes drugs. The median market share of the hospital referral regions was 21.6% for marketed oral anticoagulants and 12.6% for marketed non-insulin diabetes drugs. Among hospital referral regions, one additional payment (median value $13, interquartile range, $10-$18) was associated with 94 (95% confidence interval 76 to 112) additional days filled of marketed oral anticoagulants and 107 (89 to 125) additional days filled of marketed non-insulin diabetes drugs (P<0.001). Payments to specialists were associated with greater prescribing of marketed drugs than payments to non-specialists (212 v 100 additional days filled per payment of marketed oral anticoagulants, 331 v 114 for marketed non-insulin diabetes drugs, P<0.001). Payments for speaker and consulting fees for non-insulin diabetes drugs were associated with greater prescribing of marketed drugs than payments for food and beverages or educational materials (484 v 110, P<0.001).Conclusions and study limitations Payments by the manufacturers of pharmaceuticals to physicians were associated with greater regional prescribing of marketed drugs among Medicare Part D beneficiaries. Payments to specialists and payments for speaker and consulting fees were predominantly associated with greater regional prescribing of marketed drugs than payments to non-specialists or payments for food and beverages, gifts, or educational materials. As a cross sectional, ecological study, we cannot prove causation between payments to physicians and increased prescribing. Furthermore, our findings should be interpreted only at the regional level. Our study is limited to prescribing by physicians and the two drug classes studied.

Smoke from forest fires blanketed the Indonesian islands of Kalimantan and Sumatra in late 1997. Population-based longitudinal survey data are combined with satellite measures of aerosol levels to assess the impact of the fires on adult health. To account for unobserved differences between haze and non-haze areas, we compare changes in health of individual respondents. Between 1993 and 1997, individuals exposed to haze experienced greater increases in difficulties with activities of daily living than their counterparts in non-haze areas. Results for respiratory and general health, though more complicated to interpret, suggest the haze had a negative impact on these dimensions of health.

Objective To assess the feasibility of a Mindfulness-based stress reduction (MBSR) program for adolescents with widespread chronic pain and other functional somatic symptoms, and to make preliminary assessments of its clinical utility. Study design Three cohorts of subjects completed an 8-week MBSR program. Child- and parent-completed measures were collected at baseline and 8 and 12 weeks later. Measures included the Functional Disability Inventory (FDI), the Fibromyalgia/Symptom Impact Questionnaire (FIQR/SIQR), the Pediatric Quality of Life Inventory (PedsQL), the Multidimensional Anxiety Scale (MASC2), and the Perceived Stress Scale (PSS). Subjects and parents were interviewed following the program to assess feasibility. Results Fifteen of 18 subjects (83%) completed the 8-week program. No adverse events occurred. Compared with baseline scores, significant changes were found in mean scores on the FDI (33% improvement, p=0.026), FIQR/SIQR (26% improvement, p=0.03), and MASC2 (child: 12% improvement, p=0.02; parent report: 17% improvement, p=0.03) at 8 weeks. MASC2 scores (child and parent) and PSS scores were significantly improved at 12 weeks. More time spent doing home practice was associated with better outcomes in the FDI and FIQR/SIQR (44% and 26% improvement, respectively). Qualitative interviews indicated that subjects and parents reported social support as a benefit of the MBSR class, as well as a positive impact of MBSR on activities of daily living, and on pain and anxiety. Conclusions MBSR is a feasible and acceptable intervention in adolescents with functional somatic syndromes, and has preliminary evidence for improving functional disability, symptom impact, and anxiety, with consistency between parent and child measures. Trial registration ClinicalTrials.gov: NCT02190474

We use standardized end-of-course knowledge assessments to examine student learning during the disruptions induced by the COVID-19 pandemic. Examining seven economics courses taught at four US R1 institutions, we find that students performed substantially worse, on average, in Spring 2020 when compared to Spring or Fall 2019. We find no evidence that the effect was driven by specific demographic groups. However, our results suggest that teaching methods that encourage active engagement, such as the use of small group activities and projects, played an important role in mitigating this negative effect. Our results point to methods for more effective online teaching as the pandemic continues.

We use standardized end-of-course knowledge assessments to examine student learning during the disruptions induced by the COVID-19 pandemic. Examining seven economics courses taught at four US R1 institutions, we find that students performed substantially worse, on average, in Spring 2020 when compared to Spring or Fall 2019. We find no evidence that the effect was driven by specific demographic groups. However, our results suggest that teaching methods that encourage active engagement, such as the use of small group activities and projects, played an important role in mitigating this negative effect. Our results point to methods for more effective online teaching as the pandemic continues.

BackgroundPatients with irritable bowel syndrome (IBS) are often placed on diets guided by food intolerance assays, although these have not been validated. We assessed the effects of individualised diets in patients with IBS guided by a leucocyte activation test.MethodsThis is a parallel-group, double-blind, randomised controlled trial of 58 adults with IBS seen at an academic health centre in Northeast USA. Peripheral venous blood was analysed using a leucocyte activation test; individual foods were reported to produce positive or negative results. Participants were randomised to a 4-week diet with either individualised guidance to eliminate foods with positive assay results and allow foods with negative assay results (intervention), or with individualised guidance, matched in rigour and complexity, to eliminate foods with negative assay results and allow foods with positive assay results (comparison). The primary outcome was between-group differences in the IBS Global Improvement Scale (GIS). Secondary outcomes included reductions in IBS Symptom Severity Scale (SSS) scores and increases in IBS Adequate Relief (AR) and Quality of Life (QOL) scores. An aptamer-based proteomic analysis was conducted in strong responders.ResultsThe intervention group had significantly greater increases in mean GIS score after 4 weeks (0.86 vs comparison; 95% CI 0.05 to 1.67; p=0.04) and 8 weeks (1.22 vs comparison; 95% CI 0.22 to 2.22; p=0.02). The intervention group also had significantly greater reductions in mean SSS score at 4 weeks (–61.78 vs comparison; 95% CI –4.43 to –119.14; p=0.04) and 8 weeks (–66.42 vs comparison; 95% CI –5.75 to –127.09; p=0.03). There were no significant differences between intervention and comparison groups in mean AR or QOL scores. A reduction in neutrophil elastase concentration was associated with reduced symptoms.ConclusionsElimination diets guided by leucocyte activation tests reduced symptoms. These findings could lead to insights into the pathophysiology of IBS.Trial registration numberNCT02186743.

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.

Previous empirical research has shown that Mexico's Oportunidades program has succeeded in increasing schooling and improving health of disadvantaged children. This paper studies the program's potential longer-term consequences for the poverty and inequality of these children. It adapts methods developed in DiNardo, Fortin and Lemieux (1996)