The regulation and structure of nonlife insurance in the United States

The insurance industry is underdeveloped in most developing countries because of low levels of income and wealth and because restrictive regulations inhibit the supply of insurance services. But several countries have begun to reform their insurance industries. To help those countries, the authors offer an overview of insurance regulation in the United States - and discuss the economics and market structure of nonlife insurance in entry and exit barriers, economies of scale, and conduct and performance studies. They conclude that the U.S. nonlife insurance industry exhibits low concentration at both national and state market levels. Concentration is low even on a line-by-line basis. The primary concern of regulators has been to protect policyholders from insolvency, but regulation has also often been used to protect the market position of local insurance companies against the entry of out-of-state competitors. Regulation has worked best when based on solvency monitoring, with limited restrictions on entry. It has been more harmful when it involved controls on premiums and products and on the industry's level of profitability. Over the years the industry has shown a remarkable degree of innovation, although it has also faced many serious and persistent problems. The problems include the widespread crisis in liability (including product liability and medical malpractice), the crisis in automobile insurance, the volatility of investment income, the effects of market-driven pricing and underwriting cycles, and the difficulty of measuring insurance solvency. The long-tailed lines of insurance - those that entail long delays in final settlements - are exposed to the vagaries of inflation and rising costs. Two mandatory lines - third party automobile insurance and workers'compensation (for work accidents) - account for nearly 55 percent of premiums. These two lines - plus medical malpractice, other liability, and aircraft insurance - had combined ratios well over 125 percent in 1989. The industry has some ability to collude and to set prices, but seems to be competitive and to earn profits below similarly situated financial firms. Insurance profitability is not consistently above or below normal returns, although earnings for mandatory and strictly regulated lines of automobile insurance and workers'compensation appear to be below-adequate for long-term viability.Insurance&Risk Mitigation,Non Bank Financial Institutions,Insurance Law,Environmental Economics&Policies,Financial Intermediation

Sprint interval training (SIT) is an effective method to maintain cardiorespiratory fitness (CRF) and glucose homeostasis in Scottish adolescents

The present study examined the physiological impact of a school based sprint interval training (SIT) intervention in replacement of standard physical education (SPE) class on cardio-respiratory fitness (CRF) and glucose homeostasis during the semester following summer vacation. Participants (n=49) were randomly allocated to either intervention (SIT; n=26, aged 16.9 ± 0.3 yrs) or control group who underwent standard physical education (SPE; n=23, aged 16.8 ± 0.6 yrs). CRF (VO2max) and glucose homeostasis were obtained prior-to and following 7 weeks of SIT exercise. Significant group x time interaction was observed for CRF (P<0.01) with non-significant trends for fasting insulin (P= 0.08), and HOMA-IR (P = 0.06). CRF decreased (P<0.01) in SPE such that POST intervention CRF was significantly lower (P< 0.05) in SPE. Fasting plasma glucose (P<0.01), insulin (P< 0.01) and HOMA-IR (P< 0.01) increased significantly amongst SPE. The main finding of the present study is that 7-weeks of SIT exercise is an effective method of maintaining (but not improving) CRF and fasting insulin homeostasis amongst school-going adolescents. SIT exercise demonstrates potential as a time efficient physiological adjunct to standard PE class in order to maintain CRF during the school term

The Eucational Value of the Use of a Simcapture-Feedback Process in the Training of Obstetrics and Gynecology Residents

The educational value of the use of a Simcapture-feedback process in the training of obstetrics and gynecology Residents Joseph Patruno, MD, Timothy Pellini, MD, Martin Martino, MD, Grace Bova Lehigh Valley Health Network, Allentown, Pennsylvania Abstract: Background: The basis of renowned training hospitals like LVHN is a well-defined and effectively applied method for optimal teaching, especially in the operating room. Unfortunately, many physicians don’t provide the immediate and detailed feedback most valuable to residents. Thus, video feedback and detailed surveys shown to surgeons upon procedure completion are tools used to potentially optimize the educational experience for Obstetrics and Gynecology residents in the operating room. Method: For each chosen OB/Gyn procedure the surgical field was recorded. After the surgery, detailed surveys were given to each physician to assess the resident’s performance on each particular part of the operation. A debrief was also stimulated to discuss the specific weaknesses and strengths that the resident displayed during the procedure. Later that day, an Educational Value Survey was sent to both physicians to obtain feedback on how educationally effective the video and debriefing process were. Simultaneously, the same survey was sent to a control resident and attending who had done a similar procedure without the video and survey aspect present. Results: Attending surgeons’ responses in the subject cases were significantly higher with respect to the timeliness and effectiveness of the debrief than the responses from the control cases. Generally, both attendings and residents found the surgeries with the SimCapture video and evaluation tools more educationally valuable than those without the stimulated feedback resources. Conclusions: SimCapture video feedback as well as detailed evaluation forms can enhance the teaching and learning for residents doing OB/Gyn procedures. Additionally, with this foundation in place attending surgeons are able to engage the resident in a structured debrief after a surgery. Introduction: In a teaching hospital, attending surgeons are expected to provide immediate and comprehensive feedback to residents in order to improve surgery techniques and patient care. Unfortunately this expected debrief does not always occur or often the feedback given isn’t direct & clear enough to be effective. However the SimCapture technology used for video feedback as well as a series of surveys filled out by both surgeons are possible resources that can be utilized in order to optimize the educational value of a procedure. According to the BID model for teaching in the operating room created by Dr. Nicole K. Roberts (2009) the learner must be “actively involved in creating learning objective & proposing how instruction might be extended to future practice” (p.300). This model is easy to use because it solely requires brief conversation between attending and resident while scrubbing, operating, & closing. By utilizing these events that occur at every operation, very little additional time is required from either surgeon. Furthermore, the educational value of written assessments regarding resident’s surgical performance has also been rendered valid and useful. Such assessments “encourage the faculty and the resident to focus on areas of demonstrated competence and those areas needing improvement” (Dougherty et all, 2013, p.333). Detailed evaluation forms allow for the surgeons to reflect on each step of the procedure. These forms are most useful when completed directly after the surgery, allowing for more comprehensive recollection of the operation. Likewise, the resident benefits more from the stimulated debrief soon after he finishes the procedure. The stimulated debrief in this project utilizes the “Operative Performance Rating System “ (OPRS). Using this form, both surgeons can assess the resident’s performance for each part of the procedure. Although these evaluations have not get been validated for Ob/Gyn procedures, they have proven to be especially effective in general surgery. Unlike more broad evaluations of technical skill, the OPRS offers a “controlled, systematic, observation/evaluation and appropriate sampling of performance across the entire performance domain” (Larson et al, 2005, p. 646). Thus, the OPRS allows evaluators to rate the residents on a likert scale for each step of the procedure as well as more general surgical flow and knowledge. Detailed feedback like this provides the residents with specific surgical skills and methods that need improvement. The objective of our study is to determine the educational value of SimCapture video feedback as well as post-procedure evaluation forms with respect to Obstetrical and Gynecological procedures. We anticipate that these tools will enhance both the learning and teaching process for the residents and attendings respectively. Materials and Methods: In order to evaluate whether the SimCapture video and survey forms combined made a positive effect on the educational value of an operation we filmed about 40 OR cases. Among these cases included Cesarean sections, Robotically-assisted Laparoscopic Hysterectomies, Hysteroscopies, Bilateral Tubal Ligations, and Laparoscopically-Assisted Vaginal Hysterectomies. After choosing several cases to record from the OR list, the team found both the attending and resident on the case and informed them on the SimCapture project and asked for permission to film their upcoming procedure in the OR. Upon consent, the team set up the video system and oriented the OR staff to the project. During the procedure, only the surgeon’s hands were recorded. The residents were all assigned a number; thus, a resident number was associated with each video instead of individual’s names. Annotations were made within the video to indicate when the resident is operating. After the procedure was complete, both attending and resident were asked to fill out both a milestone form and an OPRS evaluation. The OPRS having questions specific to each step of the particular type of case. Having completed the surveys, the resident was asked to reflect on what he thought his weaknesses and strengths were in that particular case. This ignited the debriefing conversation, often resulting in meaningful discussion between both surgeons regarding the resident’s technique and skill level. Later that day, a survey was sent to both the attending and resident to assess the educational significance of their procedure that day. Among these questions were ones about the questions asked, the effectiveness of the debrief, and the overall educational value of the case. Each questions required a response between 1-5, usually 1 relating to least educational and 5 being most educationally valuable. Concurrently, another set of the same educational value surveys was sent to a control attending and resident that had participated in a similar case that day. Thus, the control data would allow us to evaluate the overall effect of the SimCapture and feedback process on the educational process. Using these cases for controls allows us to determine how well residents are regularly being effectively taught, especially via a debrief after the procedure. The questions in this survey asked responders to answer the following questions on a likert scale 1 being “strongly disagree” and 5 being “strongly agree”. 1. I/the resident came adequately prepared 2. Optimal training provided? 3. The questions asked by the attending were fair & appropriately challenging 4. There was an appropriate debrief before, during & after the case? 5. My opinion of my performance correlates with the attending’s perception of my performance. 6. Specific, timely, & valuable feedback was given. 7. I would rate the overall educational value of this case as… (1-Poor and 5-Excellent) The responses were then compiled into four separate groups: control residents, subject residents, control attendings, and subject attendings. The mean response for each question for each group was calculated. Then the controls’ and subjects’ mean responses were compared to assess the overall educational effect of the video and feedback process. Statistical analysis was also done. A t-test was performed to obtain p-values for the data set. Using the results of the t-test, we were able to determine the statistical significance and validity of each question for the residents (controls and subjects) and attendings (controls and subjects). Results: By the end of our six-week collection period, forty total cases were recorded: seventeen Cesarean Sections, eight Robotic Hysterectomies, twelve Hysteroscopies, and three Bilateral Tubal Ligations. We also collected fifteen control cases: four Cesarean Sections, one Robotic Hysterectomy, eight Hysteroscopies, and two Bilateral Tubal Ligations. Twelve out of twenty-three OB/Gyn residents participated in the study: two interns, five in their second year of residency, three in their third, and two in their fourth. Twenty-two different attendings participated as well. A brief comparison of the controls and subjects was done with the mean responses to each question. These results are as follows. The more statistically significant differences will be further discussed. Refer to Table 1 in the Appendix to see the average values for each question. 1. I/the resident came adequately prepared Residents: Similar responses regardless of process Attendings: Similar responses regardless of process 2. Optimal training provided? Residents: Interestingly, the controls felt more optimally trained in the OR than the subject did Attendings: Similar responses regardless of process 3. The questions asked by the attending were fair & appropriately challenging Residents: Controls’ responses were higher; felt they had been asked more appropriate questions Attendings: Controls’ responses were slightly higher 4. There was an appropriate debrief before, during & after the case? Residents: Subjects’ responses were higher. Not surprisingly, as there was better communication during the debrief developed by the process Attendings: Subjects’ responses were generally much higher. The attendings were alert to the stimulated debriefing process 5. My opinion of my performance correlates with the attending’s perception of my performance. Residents: Similar responses regardless of process Attendings: Similar responses regardless of process 6. Specific, timely, & valuable feedback was given Residents: Similar responses; feel they are getting feedback in either process Attendings: Subjects’ responses were higher; attendings felt much more confident regarding their feedback with this process guiding them 7. I would rate the overall educational value of this case as… (1-Poor and 5-Excellent) Residents: Subjects’ responses were higher. The educational value ties together importance of preparation, supervision, education, debriefing, and feedback, several of which the SimCapture/feedback process aimed to enhance. Attendings: Subjects’ responses were higher as well. The following is a chart (Figure 1) of the average response for residents (both control and subject) and the p values from the t-test. The highlighted columns are the values that are most statistically significant. (Figure 1) The following is a chart (Figure 2) of the average response for attendings (both control and subject) and the p values from the t-test. The highlighted columns are the values that are most statistically significant. (Figure 2) Furthermore, in the subject’s surveys there was a question about the value of using SimCapture video as a form of feedback. 87% of subject cases had residents who saw value in using video as a method of feedback. 75% of the subject cases had attendings who felt the video feedback could be useful for optimal teaching and learning Discussion: The residents in the subject cases found the surgeries with the SimCapture and feedback process generally more educationally valuable. Many of the residents enjoyed the opportunity to receive direct and detailed feedback from their mentors. The residents also benefitted from reflecting on their own performance, considering both their strengths and weaknesses. However, the residents’ responses that were particularly statistically significant were about the questions asked during surgery; interestingly, the controls felt that the questions asked were more fair and appropriate than the subjects. This difference may be due to the presence of the SimCapture equipment and team. This addition to the OR may have made the attendings feel as though the resident was in the spotlight and, therefore, did not need as many questions. The attendings who participated in the SimCapture and feedback process were able to recognize the educational importance of the debrief after a procedure. The attendings in subject cases felt significantly more confident about the timeliness and value of the feedback they gave to the resident after the procedure. By stimulating a debrief session between both surgeons directly after the procedure, attendings were able to recall specific challenges and strengths the resident displayed in the surgery. Thus, they felt they were able to deliver complete and procedure-specific criticism to the residents. Additionally the attendings also became more aware of the debriefing process. Many attendings further discovered the value and effectiveness of giving immediate, detailed feedback. Some of the anonymous comments left on the educational value survey were, “I need to debrief more. We have to go after cases to meet the next patient and sometime don\u27t take the time that we should be”… “I may ask the resident more questions during the case to assess their understanding”. Thus, this process increased personal teaching awareness, hopefully motivating the attendings to provide more comprehensive and timely feedback to the residents after a procedure. Regarding the use of SimCapture video as feedback, most of the faculty and residents who participated in the cases felt the video technology could be an effective and useful form of feedback. Several surgeons requested to view their videos upon completion and were able to easily visualize their weaknesses and strengths with the objective point of view on the camera. One of the limits of this research was the lack of a large cohort of control cases. Due to our time constraint, we were unable to get the widespread responses we had hoped for both control and subject cases. Additionally many residents and attednings did not fill out the educational value surveys at all. Others completed them days after the surgery, which could possibly limit their ability to recall the specifics of the residents’ performances in the particular cases. Lastly, in some of the subject cases we were not able to stimulate a debrief due the surgeon’s schedules. In these cases both surgeons filled out the OPRS evaluations but were unable to discuss the resident’s performance in the procedure. The lack of this debrief may have affected our final response data. Conclusion: Overall the SimCapture video and the OPRS evaluations feedback method was educationally valuable. Attendings especially found the guided feedback process specifically helpful and effective. We expect that attendings will try to incorporate more timely and detailed feedback to their residents in their everyday practice. The detailed OPRS evaluations provided residents with specific areas of technique that need improvements. By enhancing the teaching and learning process in the OR, residents are able to learn more advanced skills faster and more efficiently. Attendings are able to assess the resident’s direct areas of weakness or strength with a simple feedback mechanism. Essentially, the SimCapture with feedback process can potentially advance the way residents are trained, thus improving patient care. Acknowledgements: Thank you to my project mentor Dr. Joseph Patruno, as well as Dr. Timothy Pellini, Dr. Martin Martino, Dr. Hubert Huang, Diane Leuthard, the library services, and all the residents, physicians, nurses, and faculty in the OB/GYN department. This project would not have been possible without your support. Finally, thank you to Dr. Joseph Napolitano and the Dorothy Rider Pool Health Care Trust for giving me this opportunity and incredible experience. References: Dougherty, P, Kasten, S.J., Reynolds, R.K., Prince, M.E., Lypson, M.L. (2013, June). Intraoperative Assessment of Residents. Jornal of Graduate Medicine, 333-334. http://dx.doi.org/10.4300/JGME-D-13-00074.1 Larson, J.L., Williams, R. G., Ketchum, J, Boehler, M.L., Dunnington, G.L. (2005, October). Feasibility, reliability, and validity of operative performance rating system for evaluating surgery residents.Surgery, 138 (4), 640-649. http://dx.doi.org/10.1016/j.surg.2005.07.017 Levy, B. (2012, April). Experience Counts. Obstetrics & Gynecology, 119(4), 693-694. Roberts, N.K., Williams, R.G., Kim, M.J., Dunnington, G.L. (2009, February). The Briefing, Intraoperative Teaching, Debriefing Model for Teaching in the Operating Room. Journal of the American College of Surgeons, 208(2), 299-303. http://dx.doi.org/10.1016/j/jamcollsurg.2008.10.024 Swing, S.R. (2007).The ACGME outcome project: retrospective and prospective. Medical Teacher, 29, 648-654. http://dx.doi.org/10.1080/0142159070139290

From bottom-up to top-down control of invertebrate herbivores in a retrogressive chronosequence

In the long-term absence of disturbance, ecosystems often enter a decline or retrogressive phase which leads to reductions in primary productivity, plant biomass, nutrient cycling and foliar quality. However, the consequences of ecosystem retrogression for higher trophic levels such as herbivores and predators, are less clear. Using a post-fire forested island-chronosequence across which retrogression occurs, we provide evidence that nutrient availability strongly controls invertebrate herbivore biomass when predators are few, but that there is a switch from bottom-up to top-down control when predators are common. This trophic flip in herbivore control probably arises because invertebrate predators respond to alternative energy channels from the adjacent aquatic matrix, which were independent of terrestrial plant biomass. Our results suggest that effects of nutrient limitation resulting from ecosystem retrogression on trophic cascades are modified by nutrient-independent variation in predator abundance, and this calls for a more holistic approach to trophic ecology to better understand herbivore effects on plant communities

Responding to Vaccine Safety Signals during Pandemic Influenza: A Modeling Study

Background: Managing emerging vaccine safety signals during an influenza pandemic is challenging. Federal regulators must balance vaccine risks against benefits while maintaining public confidence in the public health system. Methods: We developed a multi-criteria decision analysis model to explore regulatory decision-making in the context of emerging vaccine safety signals during a pandemic. We simulated vaccine safety surveillance system capabilities and used an age-structured compartmental model to develop potential pandemic scenarios. We used an expert-derived multi-attribute utility function to evaluate potential regulatory responses by combining four outcome measures into a single measure of interest: 1) expected vaccination benefit from averted influenza; 2) expected vaccination risk from vaccine-associated febrile seizures; 3) expected vaccination risk from vaccine-associated Guillain-Barre Syndrome; and 4) expected change in vaccine-seeking behavior in future influenza seasons. Results: Over multiple scenarios, risk communication, with or without suspension of vaccination of high-risk persons, were the consistently preferred regulatory responses over no action or general suspension when safety signals were detected during a pandemic influenza. On average, the expert panel valued near-term vaccine-related outcomes relative to long-term projected outcomes by 3∶1. However, when decision-makers had minimal ability to influence near-term outcomes, the response was selected primarily by projected impacts on future vaccine-seeking behavior. Conclusions: The selected regulatory response depends on how quickly a vaccine safety signal is identified relative to the peak of the pandemic and the initiation of vaccination. Our analysis suggested two areas for future investment: efforts to improve the size and timeliness of the surveillance system and behavioral research to understand changes in vaccine-seeking behavior

The meaning of caring for patients with cancer among traditional medicine practitioners in Uganda: A grounded theory approach

Traditional medicine practitioners (TMPs) are a critical part of healthcare systems in many sub-Saharan African countries and play vital roles in caring for patients with cancer. Despite some progress in describing TMPs’ caring experiences in abstract terms, literature about practice models in Africa remains limited. This study aimed to develop a substantive theory to clarify the care provided by TMPs to patients with cancer in Uganda. This study adhered to the principal features of the modified Straussian grounded theory design. Participants were 18 TMPs caring for patients with cancer from 10 districts in Uganda, selected by purposive and theoretical sampling methods. Researcher-administered in-depth interviews were conducted, along with three focus group discussions. Data were analyzed using constant comparative analysis. The core category that represented TMPs’ meaning of caring for patients with cancer was “Restoring patients’ hope in life through individualizing care.” TMPs restored patients’ hope through five main processes: 1) ensuring continuity in the predecessors’ role; 2) having full knowledge of a patient’s cancer disease; 3) restoring hope in life; 4) customizing or individualizing care, and 5) improving the patient’s condition/health. Despite practice challenges, the substantive theory suggests that TMPs restore hope for patients with cancer in a culturally sensitive manner, which may partly explain why patients with cancer continue to seek their services. The findings of this study may guide research, education, and public health policy to advance traditional medicine in sub-Saharan Africa

Strategies from a multi-national sample of electroconvulsive therapy (ECT) services: Managing anesthesia for ECT during the COVID-19 pandemic

Electroconvulsive therapy (ECT) is important in the management of severe, treatment-resistant, and life-threatening psychiatric illness. Anesthesia supports the clinical efficacy and tolerability of ECT. The COVID-19 pandemic has significantly disrupted ECT services, including anesthesia. This study documents strategies for managing ECT anesthesia during the pandemic. Data were collected between March and November 2021, using a mixed-methods, cross-sectional, electronic survey. Clinical directors in ECT services, their delegates, and anesthetists worldwide participated. One hundred and twelve participants provided quantitative responses to the survey. Of these, 23.4% were anesthetists, and the remainder were ECT clinical directors. Most participants were from Australia, New Zealand, North America, and Europe. Most were located in a public hospital, in a metropolitan region, and in a ‘medium/high-risk’ COVID-19 hotspot. Half of the participants reported their services made changes to ECT anesthetic technique during the pandemic. Services introduced strategies associated with anesthetic induction, ventilation, use of laryngeal mask airways, staffing, medications, plastic barriers to separate staff from patients, and the location of extubation and recovery. This is the first multi-national, mixed-methods study to investigate ECT anesthesia practices during the COVID-19 pandemic. The results are vital to inform practice during the next waves of COVID-19 infection, ensuring patients continue to receive ECT

Religion as practices of attachment and materiality: the making of Buddhism in contemporary London

This article aims to explore Buddhism’s often-overlooked presence on London’s urban landscape, showing how its quietness and subtlety of approach has allowed the faith to grow largely beneath the radar. It argues that Buddhism makes claims to urban space in much the same way as it produces its faith, being as much about the practices performed and the spaces where they are enacted as it is about faith or beliefs. The research across a number of Buddhist sites in London reveals that number of people declaring themselves as Buddhists has indeed risen in recent years, following the rise of other non-traditional religions in the UK; however, this research suggests that Buddhism differs from these in several ways. Drawing on Baumann’s (2002) distinction between traditionalist and modernist approaches to Buddhism, our research reveals a growth in each of these. Nevertheless, Buddhism remains largely invisible in the urban and suburban landscape of London, adapting buildings that are already in place, with little material impact on the built environment, and has thus been less subject to contestation than other religious movements and traditions. This research contributes to a growing literature which foregrounds the importance of religion in making contemporary urban and social worlds

Electronic Conductance and Thermopower of Cross-Conjugated and Skipped-Conjugated Molecules in Single-Molecule Junctions

We report a combined experimental and theoretical study of a series of thiomethyl (SMe) anchored cross-conjugated molecules featuring an acyclic central bridging ketone and their analogous skipped-conjugated alcohol derivatives. Studies of these molecules in a gold|single-molecule|gold junction using scanning tunneling microscopy-break junction techniques reveal a similar conductance (G) value for both the cross-conjugated molecules and their skipped-conjugated partners. Theoretical studies based on density functional theory of the molecules in their optimum geometries in the junction reveal the reason for this similarity in conductance, as the predicted conductance for the alcohol series of compounds varies more with the tilt angle. Thermopower measurements reveal a higher Seebeck coefficient (S) for the cross-conjugated ketone molecules relative to the alcohol derivatives, with a particularly high S for the biphenyl derivative 3a (−15.6 μV/K), an increase of threefold compared to its alcohol analog. The predicted behavior of the quantum interference (QI) in this series of cross-conjugated molecules is found to be constructive, though the appearance of a destructive QI feature for 3a is due to the degeneracy of the HOMO orbital and may explain the enhancement of the value of S for this molecule