Introduction: An Unsettled Time from \u3cem\u3eAmerican Political Development and the Trump Presidency\u3c/em\u3e

As the words of his inaugural address echoed across a rain- soaked National Mall, Donald Trump cut a hole in time. His presidency, he said, marked a breaking point in American politics. No longer would a “small group” of elites reap the benefits of government while “forgotten Americans” bore the cost. “Now,” Trump suggested, “we are only looking to the future.” Even so, the speech telegraphed a dystopian pre sent; the United States had become a landscape of rusted- out factories, cities teeming with crime, and national borders defenseless against terrorist threats. Gone was the promised land that Trump’s predecessors foretold in their inaugural speeches, the “city on a hill” that America was destined to be. Trump identified few, if any, sources of political possibility. America would be “made great again” not through providence, but by Trump himself: “I will fight for you with every breath in my body— and I will never, ever let you down.” Rather than binding the nation through conciliation and compromise, Trump promised nationalism: “The bedrock of our politics,” he said, “will be a total allegiance to the United States of America.” He labeled his foreign policy with a phrase burdened with an isolationist and anti- Semitic history: “America First.” ..

From \u27Trial and Error\u27 to Major Reform: The Politics of Medicare Demonstration Projects

Facing fragmented institutions and partisan polarization, officials in the United States often attempt to engineer policy change without assembling new legislative majorities. To this end, they have increasingly employed demonstration projects, policy innovations undertaken by administrative agencies designed to test alternative approaches to implementation or service delivery on a limited segment of the target population and for a limited period of time. Despite the increasing importance of demonstration projects, they are an undertheorized source of policy change. In this article, we conceptualize demonstration projects as part of a class of experimental institutions that, while incremental in scope, have the potential to \u27scale up\u27 into more substantial reforms. Data from three Medicare demonstrations suggest that policy change is more likely when programmes generate strong support constituencies; minimize administrative and infrastructural costs; are undertaken in contexts with few veto points; and align with the time horizons of elected officials

COVID-19, Poverty Reduction, and Partisanship in Canada and the United States

Poor people proved especially vulnerable to economic disruption during the coronavirus disease (COVID-19) pandemic, which highlighted the importance of poverty reduction as a policy concern. In this article, we explore the politics of poverty reduction during the COVID-19 crisis in Canada and the United States, two liberal welfare-state regimes where poverty reduction is a key policy issue. We show that, since the beginning of the pandemic, policies likely to reduce poverty significantly have been adopted in both Canada and the United States. Yet, this poverty reduction logic has emerged in different ways in the two countries—with the United States embracing more significant departures from its policy status quo. This situation leads us to ask the following question: in each country, what are the political conditions under which public policies susceptible of reducing poverty are enacted? To answer this question, we study the politics of poverty reduction both before and during the pandemic, as we suggest that grasping the evolution of partisan and electoral patterns over time is necessary to explain what happened during the pandemic, whose impact is closely related to how it interacts with such patterns. Our analysis suggests the need to consider more carefully the impact of both crises and partisanship on social policy, including poverty reduction

Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis

Objectives To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults. Design A systematic review and metaanalysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun before discharge on healthcare cost and resource use outcomes. MEDLINE, EMBASE, and the Cochrane Library databases were searched for all English‐language articles published between 1990 and April 2016. Setting Hospital or skilled nursing facility. Participants Older adults with informal caregivers discharged to a community setting. Measurements Readmission rates, length of and time to post‐discharge rehospitalizations, costs of postdischarge care. Results Of 10,715 abstracts identified, 15 studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control participants. Discharge planning interventions with caregiver integration were associated with a 25% fewer readmissions at 90 days (relative risk (RR) = 0.75, 95% confidence interval (CI) = 0.62–0.91) and 24% fewer readmissions at 180 days (RR = 0.76, 95% CI = 0.64–0.90). The majority of studies reported statistically significant shorter time to readmission, shorter rehospitalization, and lower costs of postdischarge care among discharge planning interventions with caregiver integration. Conclusion For older adults discharged to a community setting, the integration of caregivers into the discharge planning process reduces the risk of hospital readmission

Association of Variants in the SPTLC1 Gene With Juvenile Amyotrophic Lateral Sclerosis

Importance: Juvenile amyotrophic lateral sclerosis (ALS) is a rare form of ALS characterized by age of symptom onset less than 25 years and a variable presentation.Objective: To identify the genetic variants associated with juvenile ALS.Design, Setting, and Participants: In this multicenter family-based genetic study, trio whole-exome sequencing was performed to identify the disease-associated gene in a case series of unrelated patients diagnosed with juvenile ALS and severe growth retardation. The patients and their family members were enrolled at academic hospitals and a government research facility between March 1, 2016, and March 13, 2020, and were observed until October 1, 2020. Whole-exome sequencing was also performed in a series of patients with juvenile ALS. A total of 66 patients with juvenile ALS and 6258 adult patients with ALS participated in the study. Patients were selected for the study based on their diagnosis, and all eligible participants were enrolled in the study. None of the participants had a family history of neurological disorders, suggesting de novo variants as the underlying genetic mechanism.Main Outcomes and Measures: De novo variants present only in the index case and not in unaffected family members.Results: Trio whole-exome sequencing was performed in 3 patients diagnosed with juvenile ALS and their parents. An additional 63 patients with juvenile ALS and 6258 adult patients with ALS were subsequently screened for variants in the SPTLC1 gene. De novo variants in SPTLC1 (p.Ala20Ser in 2 patients and p.Ser331Tyr in 1 patient) were identified in 3 unrelated patients diagnosed with juvenile ALS and failure to thrive. A fourth variant (p.Leu39del) was identified in a patient with juvenile ALS where parental DNA was unavailable. Variants in this gene have been previously shown to be associated with autosomal-dominant hereditary sensory autonomic neuropathy, type 1A, by disrupting an essential enzyme complex in the sphingolipid synthesis pathway.Conclusions and Relevance: These data broaden the phenotype associated with SPTLC1 and suggest that patients presenting with juvenile ALS should be screened for variants in this gene.</p

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

Background Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories. Methods We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5–19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI &lt;18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school&#x2;aged children and adolescents, we report thinness (BMI &lt;2 SD below the median of the WHO growth reference) and obesity (BMI &gt;2 SD above the median). Findings From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness. Interpretation The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesit