How can subnational governments develop and deliver distinctive policy agendas?

Emily St.Denny, Andrew Connell, and Steve Martin analyse two contrasting attempts by the Welsh Government to develop and deliver distinctive subnational policies. They demonstrate the importance of looking beyond formal institutional powers and of paying attention to policymakers’ political skills and visibility, as well as to the strategies and tactics that they employ in deploying formal powers

How can subnational governments deliver their policy objectives in the age of austerity? Reshaping homelessness policy in Wales

This article explores how a devolved government in a small country, faced with external constraints beyond its immediate control, can deploy policy resources to shape a distinctive approach to public services. We analyse recent homelessness policy in Wales using the NATO (Nodality, Authority, Treasure, Organisation) typology of tools of government proposed by Hood and Margetts, and show how this can be applied usefully to understand the choices that governments must make in conducting relationships with other institutions. We conclude that a combination of Nodality and Authority provide powerful resources for a subnational government which has only limited formal powers and fiscal autonomy

Vital Access: How Policymakers Can Streamline the Cancer Care Journey

Patients' odds of surviving blood cancer often hinge on their ability to access specialists who can evaluate, diagnose, and treat them with optimal treatments as quickly as possible. But too often, patients encounter roadblocks that prevent them from accessing the best care and, in some cases, benefiting from incredible advancements. Recent data reveal continued disparities in outcomes for minority populations in particular.Accessing medically necessary and high-quality blood cancer care in the United States is a process that remains overly complex and contingent on factors that are steeped in systemic, socioeconomic, and racial disparities. Numerous factors impact access, but a fragmented insurance system and similarly fragmented federal and state policies that set the rules for that insurance system are major contributors. Studies have noted the impact of narrow networks, which can restrict access to some specialty care providers such as hospitals designated as "cancer centers" or "comprehensive cancer centers" by the National Cancer Institute (NCI). Narrow networks are increasingly common in commercial insurance plans in the individual and group markets and in Medicaid-managed care organizations (MCOs). Studies have also shown that cancer patients with certain types of insurance, such as Medicaid–which covers low-income people, a disproportionate share of whom are people of color–are more likely to experience worse mortality rates. These disparities in coverage and access contribute to significant inequities by income, race, ethnicity, and other factors.In the past three-plus decades, we have seen an explosion of new therapies, including immunotherapy (such as CAR T-cell) and other personalized medicine approaches that target therapies to an individual based on a range of phenotypic and genomic factors.The policy frameworks that govern insurance have not kept pace with advances in cancer treatment, and they continue to contribute to systemic inequities that prevent access to high-quality blood cancer care. Recent efforts by federal regulators to update access-related standards still fall short of ensuring equitable access to quality blood cancer care for all. And some elements of these frameworks have remained largely unchanged for decades. Meaning consumers still struggle to navigate their options when purchasing a plan and access medically appropriate treatment when a diagnosis is received.This report offers nine recommendations in five reform pathways for state and federal policymakers to consider, as they work toward developing insurance regulations that advance a more equitable system of care–one that enables patients with blood cancer to access appropriate treatment and that maximizes the potential for long-term survival. Each of these reform pathways addresses specific deficiencies in the current insurance policy frameworks, and each is critical to pursue in order to ensure a more equitable coverage landscape for patients and familie

Can meso-governments use metagovernance tools to tackle complex policy problems?

In recent years, a range of countries have devolved significant powers, responsibilities and funding to the regional level. This paper explores how and why the resulting meso-governments may use the tools of metagovernance. A detailed empirical analysis of homelessness policy in Wales found that skilful deployment of metagovernance tools enabled its meso-government to exploit the advantages of geographical and relational proximity to policy communities, while mitigating some of the constraints of its intermediate constitutional status, including limited formal powers and policy capacity. Junior government officials played multiple roles in homelessness networks, shaping and steering them through active network management while also participating in them. This ‘governor-participant’ role blurs the distinction made in the existing literature between ‘hands-on’ and ‘hands-off’ metagovernance tools. It also shows that, in the case of meso-governments at least, it is possible for low-ranking officials to exercise greater agency in policy development than has previously been assumed

WGS for surveillance of antimicrobial resistance:A pilot study to detect the prevalence and mechanism of resistance to azithromycin in a UK population of non-typhoidal Salmonella

Objectives: WGS and phenotypic methods were used to determine the prevalence of azithromycin resistance in Salmonella enterica isolates from the UK and to identify the underlying mechanisms of resistance.  Methods: WGS by Illumina HiSeq was carried out on 683 Salmonella spp. isolates. Known genes associated with azithromycin resistance were detected by WGS using a mapping-based approach. Macrolide resistance determinants were identified and the genomic context of these elements was assessed by various bioinformatics tools. Susceptibility testing was in accordance with EUCAST methodology (MIC ≤16 mg/L).  Results: Fifteen isolates of non-typhoidal Salmonella enterica belonging to serovars Salmonella Blockley, Salmonella Typhimurium, Salmonella Thompson, Salmonella Ridge and Salmonella Kentucky showed resistance or decreased susceptibility to azithromycin (from 6 to >16 mg/L) due to the presence of macrolide resistance genes mphA, mphB or mefB. These genes were either plasmid or chromosomally mediated. Azithromycin-resistant Salmonella Blockley isolates harboured a macrolide inactivation gene cluster, mphA-mrx-mphr(A), within a novel Salmonella azithromycin resistance genomic island (SARGI) determined by MinION sequencing. This is the first known chromosomally mediated mphA gene cluster described in salmonellae. Phylogenetic analysis and epidemiological information showed that mphA Salmonella Blockley isolates were not derived from a single epidemiologically related event. The azithromycin MICs of the 15 Salmonella spp. isolates showed that the presence of the mphA gene was associated with MIC ≥16 mg/L, while the presence of mefB or mphB was not.  Conclusions: Azithromycin resistance due to acquisition of known macrolide resistance genes was seen in four different Salmonella serovars and can be either plasmid-encoded or chromosomally encoded

The responses of brown macroalgae to environmental change from local to global scales: direct versus ecologically mediated effects

In many temperate regions, brown macroalgae fulfil essential ecosystem services such as the provision of structure, the fixation of nutrients and carbon, and the production of biomass and oxygen. Their populations in many regions around the globe have declined and/or spatially shifted in recent decades. In this review we highlight the potential global and regional drives of these changes, describe the status of regionally particularly important brown macroalgal species, and describe the capacity of interactions among abiotic and biotic factors to amplify or buffer environmental pressure on brown macroalgae. We conclude with a consideration of possible management and restoration measures

Evaporation, seepage and water quality management in storage dams: a review of research methods

One of the most significant sources of water wastage in Australia is loss from small storage dams, either by seepage or evaporation. Over much of Australia, evaporative demand routinely exceeds precipitation. This paper outlines first, methodologies and measurement techniques to quantify the rate of evaporative loss from fresh water storages. These encompass high-accuracy water balance monitoring; determination of the validity of alternative estimation equations, in particular the FAO56 Penman- Monteith ETo methodology; and the commencement of CFD modeling to determine a 'dam factor' in relation to practical atmospheric measurement techniques. Second, because the application of chemical monolayers is the only feasible alternative to the high cost of physically covering the storages to retard evaporation, the use of cetyl alcohol-based monolayers is reviewed, and preliminary research on their degradation by photolytic action, by wind break-up and by microbial degradation reported. Similarly, preliminary research on monolayer visualisation techniques for field application is reported; and potential enhancement of monolayers by other chemicals and attendant water quality issues are considered

Injury, Interiority, and Isolation in Men’s Suicidality

Men’s high suicide rates have been linked to individual risk factors including history of being abused as a child, single marital status, and financial difficulties. While it has also been suggested that the normative influences of hegemonic masculinities are implicated in men’s suicide, the gendered experiences of male suicidality are poorly understood. In the current photovoice study, 20 men who previously had suicidal thoughts, plans, and/or attempts were interviewed as a means to better understanding the connections between masculinities and their experiences of suicidality. The study findings revealed injury, interiority, and isolation as interconnected themes characterizing men’s suicidality. Injury comprised an array of childhood and/or cumulative traumas that fueled men’s ruminating thoughts inhibiting recovery and limiting hopes for improved life quality. In attempting to blunt these traumas, many men described self-injuring through the overuse of alcohol and other drugs. The interiority theme revealed how suicidal thoughts can fuel hopelessness amid summonsing remedies from within. The challenges to self-manage, especially when experiencing muddled thinking and negative thought were evident, and led some participants to summons exterior resources to counter suicidality. Isolation included separateness from others, and was linked to abandonment issues and not having a job and/or partner. Self-isolating also featured as a protection strategy to avoid troubling others and/or reducing exposure to additional noxious stimuli. The study findings suggest multiple intervention points and strategies, the majority of which are premised on promoting men’s social connectedness. The destigmatizing value of photovoice methods is also discussed

Mutations in GATA2 cause primary lymphedema associated with a predisposition to acute myeloid leukemia (Emberger syndrome).

We report an allelic series of eight mutations in GATA2 underlying Emberger syndrome, an autosomal dominant primary lymphedema associated with a predisposition to acute myeloid leukemia. GATA2 is a transcription factor that plays an essential role in gene regulation during vascular development and hematopoietic differentiation. Our findings indicate that haploinsufficiency of GATA2 underlies primary lymphedema and predisposes to acute myeloid leukemia in this syndrome