The Economics and Politics of Contracting out with the Private Sector: Evidence from the US Transit Industry

The paper studies contracting practices in the US transit industry. It employs the methods of transaction cost economics and public choice theory to develop an empirical model of bus contracting in the US transit industry. The empirical results shed light on why transit services in the US remain largely public, despite many attempts to introduce competition by contracting out services to the private sector. The results show that the decision by transit agencies to contract out with the private sector is constrained by the transaction costs of contracting and the institutional and subsidy arrangements that govern the transit industry in the US. Services that require idiosyncratic investments to provide large densities of passengers are less likely to be contracted out than those services that are provided using standard, small vehicles. Similarly, increases in federal subsidies and dedicated subsidies are found to discourage contracting out with the private sector. On the other hand, increases in state and local subsidies, other things being equal, encourage contracting. Agencies that have high labor costs –– indicating strong labor unions –– are less likely to contract out. In light of these findings, the paper concludes that piecemeal contracting out of services is not likely to increase the role of the private sector in the provision of public transit services. Structures of subsidies and federal arrangements creates intertwined incentives that discourage contracting by transit agencies, thus foiling the attempts to increase efficiencies by establishing competition for transit markets.Institute of Transport and Logistics Studies. Faculty of Economics and Business. The University of Sydne

Esophageal mucosal integrity improves after laparoscopic antireflux surgery in children with gastroesophageal reflux disease

Background: Esophageal intraluminal baseline impedance reflects the conductivity of the esophageal mucosa and may be an instrument for in vivo evaluation of mucosal integrity in children with gastroesophageal reflux disease (GERD). Laparoscopic antireflux surgery (LARS) is a well-established treatment option for children with proton pump inhibitory (PPI) therapy resistant GERD. The effect of LARS in children on baseline impedance has not been studied in detail. The aim of this study was to evaluate the effect of LARS on baseline impedance in children with GERD. Methods: This is a prospective, multicenter, nationwide cohort study (Dutch national trial registry: NTR2934) including 25 patients [12 males, median age 6 (range 2–18) years] with PPI-resistant GERD scheduled to undergo LARS. Twenty-four hour multichannel intraluminal impedance pH monitoring (MII-pH monitoring) was performed before and 3 months after LARS. Baseline impedance was evaluated during consecutive 2-h intervals in the 24-h tracings. Results: LARS reduced acid exposure time from 8.5 % (6.0–16.2 %) to 0.8 % (0.2–2.8 %), p < 0.001. Distal baseline impedance increased after LARS from 2445 Ω (1147–3277 Ω) to 3792 Ω (3087–4700 Ω), p < 0.001. Preoperative baseline impedance strongly correlated with acid exposure time (r −0.76, p < 0.001); however, no association between symptomatic outcome and baseline impedance was identified. Conclusions: LARS significantly increased baseline impedance likely reflecting recovery of mucosal integrity. As the change in baseline impedance was not associated with the clinical outcome of LARS, other factors besides mucosal integrity may contribute to symptom perception in children with GERD

Choledochal Malformation in Children: Lessons Learned from a Dutch National Study

Introduction: A choledochal malformation (CM) is a rare entity, especially in the Western world. We aimed to determine the incidence of CM in the Netherlands and the outcome of surgery for CM in childhood. Methods: All pediatric patients who underwent a surgical procedure for type I–IV CM between 1989 and 2014 were entered into the Netherlands Study group on choledochal cyst/malformation. Patients with type V CM were excluded from the present analysis. Symptoms, surgical details, short-term (30 days) complications were studied retrospectively. Results: Between January 1989 and December 2014, 91 pediatric patients underwent surgery for CM at a median age of 2.1 years (0.0–17.7 years). All patients underwent resection of the extrahepatic biliary tree with restoration of the continuity via Roux-en-Y hepaticojejunostomy. Twelve patients (12%) were operated laparoscopically. Short-term complications, mainly biliary leakage and cholangitis, occurred in 20 patients (22%), without significant correlations with weight or age at surgery or surgical approach. Long-term postoperative complications were mainly cholangitis (13%) and anastomotic stricture (4%). Eight patients (9%) required radiological intervention or additional surgery. Surgery before 1 year of age (OR 9.3) and laparoscopic surgery (OR 4.4) were associated with more postoperative long-term complications. We did not observe biliary malignancies during treatment or follow-up. Conclusion: Surgery for CM carries a significant short- and long-term morbidity. Given the low incidence, we would suggest that (laparoscopic) hepatobiliary surgery for CM should be performed in specialized pediatric surgical centers with a wide experience in laparoscopy and hepatobiliary surgery

Evaluation of pregnancy and delivery in 13 women who underwent resection of a sacrococcygeal teratoma during early childhood

Background: Sacrococcygeal teratoma resection often brings changes in pelvic anatomy and physiology with possible consequences for defecation, micturition and sexual function. It is unknown, whether these changes have any gynecological and obstetric sequelae. Until now four pregnancies after sacrococcygeal teratoma resection have been described and cesarean section has been suggested to be the method of choice for delivery. We evaluated the pregnancy course and mode of delivery in women previously treated for a sacrococcygeal teratoma. Methods: The records of all patients who underwent sacrococcygeal teratoma resection after 1970 in one of the six pediatric surgical centers in the Netherlands were reviewed retrospectively. Women aged 18 years and older were eligible for participation. Patient characteristics, details about the performed operation and tumor histology were retrieved from the records. Consenting participants completed a questionnaire addressing fertility, pregnancy and delivery details. Results: Eighty-nine women were eligible for participation; 20 could not be traced. Informed consent was received from 41, of whom 38 returned the completed questionnaire (92.7%). Thirteen of these 38 women conceived, all but one spontaneously. In total 20 infants were born, 17 by vaginal delivery and 3 by cesarean section, in one necessitated by previous intra-abdominal surgery as a consequence of sacrococcygeal teratoma resection. Conversion to a cesarean section was never necessary. None of the 25 women without offspring reported involuntary childlessness. Conclusions: There are no indications that resection of a sacrococcygeal teratoma in female patients is associated with reduced fertility: spontaneous pregnancy is possible and vaginal delivery is safe for mother and child, irrespective of the sacrococcygeal teratoma classification or tumor histology

A multicomponent prehabilitation pathway to reduce the incidence of delirium in elderly patients in need of major abdominal surgery

__Background:__ Due to the increase in elderly patients who undergo major abdominal surgery there is a subsequent increase in postoperative complications, prolonged hospital stays, health-care costs and mortality rates. Delirium is

Endoscopic surgery in children and neonates: to be or not to be

August 28th 1963 Martin Luther King spoke the legendary words: “I have a dream”. January 20th 2009, almost 46 years later, Barack Obama was inaugurated as the first colored president of the United States. Today another dream has come true. With the opening of the completely renewed OR complex in the Wilhelmina Children’s hospital we can truly set off as a “Center of Excellence” for endoscopic surgery in children and neonates, with top referent patient care, education and research in the field of endoscopic surgery, and not only for the Department of Pediatric Surgery, but for all pediatric surgical specialties. This all started a mere 22 years ago, when, together with Klaas Bax, we recognized the importance of smaller scars, less pain, quicker recovery, fewer postoperative complications and a better quality of life. Since then more than 60 peer reviewed papers, directly related to endoscopic surgery in children and neonates were published, many of them nowadays still being referred to as first publication. After a first Symposium on “Sense and Non-sense” in endoscopic surgery in children in 1995, in the past two days we have organized a Symposium called “Endoscopic Surgery in Children and Neonates: to Be or Not to Be”, evaluating which endoscopic procedures have gained wide acceptance and which have not

Behavioural compliance theory

Exploring the Frontiers of International La

Behavioural compliance theory

Exploring the Frontiers of International La