The Legend of the Wehrmacht’s “Clean Hands”: The Attempt to Remove Nazism from the German Military

The legend of the Wehrmacht’s “clean hands” was created with the Himmerdoer Memorandum of 1950 and sought to disassociate the German military with its Nazi past. The legend gained popularity in the minds of the German people and successfully led to Germany’s rearmament after World War Two. Beginning in 1990, the legend was destroyed as the actions of the Wehrmacht during World War Two created a different picture than that of the legend. The Wehrmacht’s hands were far from “clean” and instead were very dirty

Report of the ACBS Task Force on the Strategies and Tactics of Contextual Behavioral Science Research

Throughout its history the strategy and tactics of contextual behavioral science (CBS) research have had distinctive features as compared to traditional behavioral science approaches. Continued progress in CBS research can be facilitated by greater clarity about how its strategy and tactics can be brought to bear on current challenges. The present white paper is the result of a 2 1/2-year long process designed to foster consensus among representative producers and consumers of CBS research about the best strategic pathway forward. The Task Force agreed that CBS research should be multilevel, process-based, multidimensional, prosocial, and pragmatic, and provided 33 recommendations to the CBS community arranged across these characteristics. In effect, this report provides a detailed research agenda designed to maximize the impact of CBS as a field. Scientists and practitioners are encouraged to mount this ambitious agenda

Genomic Relationships, Novel Loci, and Pleiotropic Mechanisms across Eight Psychiatric Disorders

Genetic influences on psychiatric disorders transcend diagnostic boundaries, suggesting substantial pleiotropy of contributing loci. However, the nature and mechanisms of these pleiotropic effects remain unclear. We performed analyses of 232,964 cases and 494,162 controls from genome-wide studies of anorexia nervosa, attention-deficit/hyper-activity disorder, autism spectrum disorder, bipolar disorder, major depression, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome. Genetic correlation analyses revealed a meaningful structure within the eight disorders, identifying three groups of inter-related disorders. Meta-analysis across these eight disorders detected 109 loci associated with at least two psychiatric disorders, including 23 loci with pleiotropic effects on four or more disorders and 11 loci with antagonistic effects on multiple disorders. The pleiotropic loci are located within genes that show heightened expression in the brain throughout the lifespan, beginning prenatally in the second trimester, and play prominent roles in neurodevelopmental processes. These findings have important implications for psychiatric nosology, drug development, and risk prediction.Peer reviewe

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Practice patterns and outcomes of repository corticotropin injection (Acthar® Gel) use in childhood nephrotic syndrome: A study of the North American Pediatric Renal Trials and collaborative studies and the Pediatric Nephrology Research Consortium

Objective: We set up a U.S. registry to examine prescription patterns and patient outcomes of repository corticotropin injection (Acthar® Gel) for childhood nephrotic syndrome. Methods: 18 participating U.S. pediatric centers performed retrospective review and prospective observation of patients < 21 years old with nephrotic syndrome treated with Acthar Gel. We captured baseline characteristics, drug regimen and duration, and disease response following treatment. Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients (39.1%) had a diagnosis of minimal change followed by focal segmental glomerulosclerosis in 16 patients (34.7%). Median age at start of treatment was 12.5 years (IQR 8.5-17.4) compared to 5.3 years at diagnosis (IQR 2.7-10.5 years). 52% were resistant to corticosteroids. The most common Acthar Gel regimen was 80IU twice a week with a median duration of 199 days (IQR 88-365). Among 37 patients with active disease, 18 (49%) were able to achieve partial or complete remission, though all patients that had a positive response were on other immunosuppressants concomitantly. Conclusion: We report the findings of the largest registry cohort of pediatric patients in the U.S. treated with Acthar Gel for clinically challenging cases of nephrotic syndrome. Acthar Gel was successful in inducing remission in approximately half of the patients with active disease at time of treatment. No predictors of response with respect to demographic data, age at start of Acthar Gel therapy, etiology of nephrotic syndrome, presence or absence of comorbidities, or steroid responsiveness was noted

Study of Rural Transportation Issues

This report is in response to Section 6206 of the Food, Conservation, and Energy Act of 2008 (PL 110 246), which directs the Secretaries of Agriculture and Transportation jointly to conduct a study of rural transportation issues. The report reviews transportation and its effect on rural communities, with an emphasis on agricultural transportation. It looks in depth into each of the four major modes of transportation commonly used by agriculture in the United States: trucking, railroads, barges, and ocean vessels, examining each in the light of its ability to meet rural America’s transportation needs now and in the future. It identifies some broad issues that merit attention from policy makers. Transportation is critical to U.S. agriculture, which raises the food for America and feeds a hungry world with its abundance. Our transportation system moves food from farms to our tables, and to ports for export to foreign markets. The four major modes work together in a seamless network, cooperating and competing with one another in a balanced and flexible system that delivers products efficiently and economically in an ever changing market. Agriculture is the largest user of freight transportation in the United States, claiming 31 percent of all ton miles transported in the United States in 2007. Much of this freight travels out of the country. Global agricultural supply and demand have changed rapidly since 1990. Corn and soybeans have increased dramatically in both consumption and production. During the past 5 years, half of American wheat was exported, along with 36 percent of the soybean crop and 19 percent of the corn crop. These exports travel from the inland areas of the United States where they are produced to borders and ports by way of a network of trucks, trains, and barges. The need for agricultural transportation will continue to increase, based on projected growth in the demand for U.S. agricultural products domestically and overseas. Transportation Issues Affecting Agricultural Shippers This study highlights some policy issues that should be examined. These issues are described in greater detail in Chapter 15: Multimodal Issues. • Transportation needs should be viewed from a system standpoint. Current governance oversees each mode of transportation—trucks, railroads, barges, and ocean vessels—separately and disparately rather than as a single interlocking system of transportation. The U.S. agricultural supply chain is a major user of the nation’s transportation system, so its needs, especially in rural areas, should be taken into account in the planning and oversight of transportation in the United States. • Ocean shipping and railroads are exempt from many antitrust rules. These exemptions have the potential to decrease competition, reduce service, and raise rates. However, since each of these industries cooperate as part of a network (although in different ways), carriers believe the limited antitrust exemptions have facilitated this cooperation. • The rapid consolidation of the railroad industry through mergers has resulted in a decrease in the unrestricted interchange of traffic, routing choices, and the level of competition among railroads. Shippers are concerned with switching limitations, restricted interchange, paper barriers, inconsistent service, high rates, excessive fuel surcharges, bottleneck rates, and the effectiveness of the rate challenge process. However, railroad productivity has increased greatly since deregulation in 1981, and rates have fallen for many shippers, although to a lesser degree for grain and coal shippers. At the same time, the financial health of the rail industry has improved, benefiting farmers and rural areas. • In 2005, Congress clarified the 100 air mile radius agricultural exemption from the hours of service rules, first granted in 1995. It means that drivers transporting an agricultural commodity or farm supplies for agricultural purposes are exempt from the maximum driving and on duty time provisions required of long haul drivers. The agricultural exemption is important because of agriculture’s unique requirements; however, questions remain about its impact on highway safety. • Funding for new waterway projects is nearly depleted, and there is a growing funding gap to finance ongoing projects. A consensus on the best way to tackle these funding issues is needed. Transportation Supports Rural America An effective transportation system supports rural economies, reducing the prices farmers pay for inputs, such as seed and fertilizer, raising the value of their crops, and greatly increasing their market access. The economies of rural areas are intertwined. As agriculture thrives, so does its supporting community. Providing effective transportation for a rural region stimulates the farms and businesses served, improving the standard of living. The interaction of agriculture and the off farm jobs it supports provides a solid base for rural communities. Agriculture is far from the largest employer in rural America. Four other sectors—services, government, retail and wholesale trade, and manufacturing—comprise 80 percent of rural employment. Agriculture is responsible for less than one in ten rural jobs but, because it is so capital intensive, it generates much more economic activity in the community than just the jobs it creates. The transportation system that contributes to the success of agriculture also supports rural manufacturing. Although the traditional view of rural America is agricultural, it is, in fact, manufacturing that is critical. Manufacturing employs 15 percent of the rural workforce. As a share of total employment, manufacturing is 42 percent more important to rural America than to metropolitan America. The availability of rail, air, and highway services is one of the most commonly cited requirements of manufacturing and commercial establishments. Transporting Biofuels The burgeoning use of biofuels contributes towards our country’s policy goals of addressing climate change, supporting the domestic economy, and reducing the nation’s dependence on imported petroleum. By 2008, U.S. ethanol production had reached 9.2 billion gallons—equivalent on an energy basis to approximately 36 percent of the gasoline produced from crude oil imported from Persian Gulf countries. Renewable fuel standard (RFS-2) goals target biofuel use to be 36 billion gallons by 2022—a very brief time in which to develop the distribution infrastructure. The biofuels most commonly used in the United States are ethanol and biodiesel. Ethanol is produced in much greater quantities than biodiesel, making its transportation requirements more complicated because more demand is placed on the transportation system. Most is currently produced from corn, and most ethanol plants are in the Corn Belt. As cellulosic ethanol is commercialized production density is likely to remain in the Midwest due to the abundance of crop residue. To achieve the RFS-2, EPA estimates that 40 unit train destinations will be needed by 2022. There are currently 13 unit train destinations. Additional unit-train destinations would create more ethanol corridors on the rail network, preventing congestion points that could develop with increased biofuel shipments. Future transportation needs will be influenced by the location of feedstocks and production facilities and the extent to which the next generation of biofuels can use existing distribution infrastructure. Transporting Coal Coal is a major source of energy in the United States. In 2006, it was responsible for one-third of domestic energy production and almost half of electric power generation. Despite the growth of alternative energy sources, coal will continue to be a major source of power for rural consumers. Because coal plays such an important role in generating electricity, its costs—including its delivery costs—are reflected in the price consumers pay for electricity. The cost of coal delivered to electric plants has increased every year since 2000. The Clean Air Act Amendments of 1990, which limited sulfur dioxide emissions, increased the demand for coal with less sulfur. Production shifted from the Appalachians to the Powder River Basin of Wyoming and Montana, which now produces 43 percent of the Nation’s coal. This western shift has resulted in the use of cleaner coal, but production is now far from river transportation systems, and competitive access to railroads is limited, raising issues about generating electricity at affordable prices. Since 1979, when the first coal mines began production in the Powder River Basin, the railroad industry has constructed the longest new rail line built in the 20th century, purchased many locomotives and coal hoppers, and made investments in existing infrastructure on routes from Wyoming to coal consumers in the Midwest and on both coasts. Railroad investment in this infrastructure has benefitted shippers of other commodities as well, since few rail lines carry only coal. Railroads are vital to coal transportation, and coal is vital to railroads. Coal accounted for 46 percent of railroad car loadings in 2007 and will continue to be important in the future. Sufficient railroad capacity is essential to move this traffic. Coal shippers are concerned about bottleneck rates and contractual paper barriers that prevent interchange with competing railroads, which can result in higher rates. Railroad service problems and high rates can directly impact rural consumers by pushing up electricity rates. Rail Competition and Agriculture Rail is the only cost effective mode of transportation available to many agricultural producers. Railroads transport nearly all the grains and oilseeds produced in Montana, more than 70 percent of the commodities produced in North Dakota, and more than half of those produced in Arizona, Oklahoma, and South Dakota. The Staggers Rail Act of 1980 economically deregulated railroads, encouraging greater reliance on free markets to promote railroad profitability and relying on competition to protect shippers and the public. The preservation and protection of competition is vital for the prosperity of agricultural producers and shippers operating with a deregulated railroad industry. Railroads have had certain exemptions from antitrust laws since 1914. When deregulation leaves the protection of customers to competition, antitrust laws are vital to protect that competition. The loss of rail to rail competition due to railroad mergers and the associated increase in market power was not foreseen by many when the Staggers Act was passed. However, the abandonment of rail lines was a predictable outcome of railroad deregulation. Prior to deregulation, the railroad industry was characterized by excess capacity. Following deregulation, railroads reduced costs by eliminating excess capacity. Many routes and branch lines were abandoned, railroads merged to eliminate duplicative facilities, and costs fell as productivity increased. The mergers increased railroad market power and profitability. Nevertheless, rates for many shippers fell from 1981 through the end of the 20th Century. Since 2004, however, rates have begun to rapidly increase as railroads reach the limits of their capacity. The level of rail to rail competition for grains and oilseeds decreased significantly between 1992 and 2007. Almost 75 percent of agricultural areas lost rail competition from 1992 to 2007, and the areas in which a railroad had a monopoly in transporting grain and oilseeds increased from 10 percent to 15 percent. At the same time, the revenue to variable cost ratio in 83 percent of those areas increased. Rail Rates The passage of the Staggers Act in 1980 enabled railroads to increase their return on investment, in part by allowing differential pricing in which different rates can be charged to different shippers and therefore some shippers bear a greater share of fixed costs than others. Agricultural commodities have historically carried higher rates than traffic more subject to competition from other modes. When selling their products farmers have little control over the prices they receive, so higher transportation costs result in lower net prices to farmers. This not only can affect the economic vitality of U.S. agriculture but also the competitiveness of U.S. agricultural exports in world markets. Nationally, not only are rail rates for grain and oilseeds higher than those for other commodities, but the rates have increased more rapidly during the four years since 2003. Rail rates for grain and oilseeds rose 46 percent from 2003 to 2007; rates for all other commodities increased 32 percent in the same period. Railroads have structured their rates to favor larger movements. There is a significant rate advantage for the largest trainload shipments of grain and oilseeds. Many costs that were once included in railroad rates have been shifted to shippers, such as car ownership. Railroads have also paid billions in merger premiums, which causes higher rates for shippers. Railroad rates have increased significantly since 2004, increasing railroad profitability. In part, this has resulted from a lack of rail capacity and a need for additional investment in locomotives, freight cars, and fixed plant. In part, the increase in rates has been a response to rising costs, as pointed out in a report by Christensen Associates in 2007. There is considerable evidence that railroad fuel surcharges recovered more than the additional cost of fuel, artificially boosting railroad profits. From 2001 to 2007, surcharges were 55 percent higher than the incremental increase in the cost of fuel. Bottleneck rate situations constrain the options available to shippers, decreasing routing efficiency, increasing rates, and increasing the market power of railroads. Rail Service The railroad share of the grain transportation market has been shrinking in recent years, in part because of changes in the way grain is marketed and in part because of increases in rail rates. The closure of many rail branch lines and a shift to “shuttle train” service by railroads has resulted in the closure of many country grain elevators, resulting in the movement of grain for longer distances on rural roads to shuttle train terminals. The U.S. railroad system is a network. The unrestricted interchange of traffic among railroads could allow shippers to achieve higher efficiency and better access to markets. In many cases, however, railroads restrict network interchange—restricting shipper choices of markets in the process—in an effort to increase profitability. The abandonment of grain branch lines has in some cases limited the markets farmers can economically reach, resulting in lower prices due to the cost of transportation or a lack of access to markets. While the concentration of grain loading at fewer points has increased the efficiency of rail transportation, it has also resulted in the movement of grain over local roads for longer distances, resulting in higher road maintenance costs for many rural communities. Railroads have since the 1990s been moving to larger capacity grain cars as a cost reducing measure. While these cars permit mainline movement of grain at lower cost, many branch lines cannot accommodate the heavier weights, and smaller railroads often lack the resources to make necessary investments in their infrastructure to handle the heavier cars. Rail Capacity Rail capacity is usually examined in terms of average tonnages carried and investment strategies, which gives a misleading picture of the situation. Capacity should be looked at in light of the specific characteristics of agricultural movements. The seasonal needs of agriculture, its regional variation, and the presence of local nodes of congestion show that attention must be paid to specific components rather than aggregate data. Rail capacity constraints were common from 2003 through the first half of 2006. Weaker demand for rail freight transportation beginning in late 2006 and a recession that began in December 2007 slowed demand and resulted in adequate rail capacity for agricultural products since the harvest of 2006. The increased use of rail transportation, which has benefited the railroads financially, also has contributed significantly to rail congestion. Each route mile during 2007 carried, on average, 171 percent more traffic in ton miles—nearly triple the traffic—than in 1980. Rail Investment Significant and sustained growth in freight demand is expected, and could double by 2035. Investment in the railroad industry, however, is not expected to keep up with demand once the economy fully recovers, especially in agricultural areas. This shortfall of investment could threaten the United States’ competitive position as a low cost supplier of high quality grain. Railroads are a capital-intensive industry. The railroad industry’s profitability has surged in recent years, finally giving it adequate revenue and increased access to capital. In an attempt to meet the rising demand for their services, railroads spent $420 billion on infrastructure between 1980 and 2007, investing almost 18 percent of their revenue on capital expenditures. According to a recent supplement to the Christensen study, Class I railroads may need to invest$89 billion by 2035 to satisfy demand. Some observers have suggested that public funding might still be needed because in a slower economy railroads have less revenue available for improving future rail capacity. Rail Rate Relief Tariff rail rates can be challenged before the Surface Transportation Board (STB) when revenue exceeds 180 percent of operating cost and the railroad has market dominance. Rail rates for contracted and exempted movements may not be challenged; STB has no jurisdiction over those movements. STB has created two classes of rate cases: coal rate and non coal rate. Coal rate cases take millions of dollars and two to four years to pursue. They have no restrictions on the amount of the award if the contested rate is higher than 180 percent of the railroad’s variable costs. Simplified procedures are available for appealing non coal rate cases, but have limits to the amounts that can be awarded. Shippers contend that the cost of pursuing these rate appeal procedures is too high and the monetary limits too low; they could result in shippers receiving little more than the cost of using them. A chemical company has used the simplified procedures, but no agricultural shipper has appealed rates using them. Barge Transportation For shippers near the inland waterways, barges offer a low-cost transportation alternative for moving their crops and fertilizer. Critics, however, argue that all the operational and maintenance costs and half the capital costs of these waterways are covered by the government through appropriations to the U.S. Army Corps of Engineers, which is responsible by law for maintaining the Nation’s inland waterways. Barges move more than a third of our corn exports and 17 percent of our soybean exports through the New Orleans region along the Mississippi River and Illinois Waterway. The market share of barges has been slowly shrinking for a number of years, and traffic on these waterways has declined. Although aging, the locks and dams on the system are generally reliable. As locks age, however, repairs and maintenance become more extensive and expensive. The balance of the Inland Waterways Trust Fund, which finances 50 percent of most of the capital costs of the inland waterways, has been declining since 2002 because expenditures have increased and revenues have declined, indicating a there is a structural imbalance between the two. It is unclear how the funding will be provided. The lack of a clear path forward on funding is of significant concern to farmers that depend on the inland waterways to move their crops to market. The funding to maintain and rehabilitate the existing infrastructure needs to remain a priority. Truck Transportation Trucking is critical for American agriculture. The industry carries 70 percent of the tonnage of agricultural, food, forest products, alcohols, and fertilizers. It links farmers, ranchers, manufacturers, and service industries to grain elevators, ethanol plants, processors, feedlots, markets, and ports. More than 80 percent of cities and communities are served exclusively by trucks. The first and last movements in the supply chain from farm to grocery store are by truck. Agriculture’s trucking needs are seasonal, requiring frequent trips during planting and harvesting seasons. Many agricultural products are perishable and time sensitive, requiring the efficiency, special handling, or refrigerated services best provided by trucks. The trucking industry is highly competitive. Half of all trucking companies own one truck, driven by the owner. This keeps rates low; the average operating costs are 95 percent of operating revenue. In 1995, Congress recognized the needs of farmers and ranchers during the busy planting and harvest seasons and provided a seasonal 100 air mile radius exemption from hours of service rules for drivers transporting agricultural commodities or farm supplies for agricultural purposes. Congress also allowed the U.S. Department of Transportation (DOT) to provide an exemption from the commercial driver’s license (CDL) requirement for drivers of farm vehicles used to transport agricultural products or supplies to or from a farm within 150 miles of the owner’s farm. However, interstate commerce case law has affected farm trucks driving s

Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala

Abstract Background Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged ≥18 years hospitalized with ARI in Guatemala. Methods We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and ≥ 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician’s discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases. Results Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults ≥18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases. Conclusions Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality