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As SARS-CoV-2 and influenza viruses co-circulate, co-infections with these viruses generate an increasing concern to public health. To evaluate the prevalence and clinical impacts of SARS-CoV-2 and influenza A virus co-infections during the 2021-2022 influenza season, SARS-CoV-2-positive samples from 462 individuals were collected from October 2021 to January 2022. Of these individuals, 152 tested positive for influenza, and the monthly co-infection rate ranged from 7.1% to 48%. Compared to the Delta variant, individuals infected with Omicron were less likely to be co-infected and hospitalized, and individuals who received influenza vaccines were less likely to become co-infected. Three individuals had two samples collected on different dates, and all three developed a co-infection after their initial SARS-CoV-2 infection. This study demonstrates high prevalence of co-infections in central Missouri during the 2021-2022 influenza season, differences in co-infection prevalence between the Delta and the Omicron waves, and the importance of influenza vaccinations against co-infections.

Objectives: We estimate associations between unemployment trajectories from ages 27-49 and physical and mental health at age 50. Methods: Data are from the U.S. National Longitudinal Survey of Youth, 1979 ( N=6434). Group-based trajectory models are used to identify unemployment trajectories. Generalized linear models with a modified Bolck, Croon, and Hagenaars (BCH) correction are used to regress health on unemployment trajectory groups. Results: We identified “Consistently Low (70%),” “Decreasing Mid-Career (18%),” and “Persistently High (12%)” unemployment trajectories. Experiencing Decreasing Mid-Career or Persistently High trajectories was associated with worse physical and mental health at age 50 than Consistently Low trajectories. Experiencing a Persistently High trajectory was associated with worse physical and mental health than a Decreasing Mid-Career trajectory. Discussion: Timing and likelihood of unemployment are associated with midlife health. Mid-Career unemployment is associated with worse physical and mental health at age 50, but not to the same degree as Persistently High unemployment.

Background Acute hematogenous osteoarticular infections (AOI), including osteomyelitis (OM) and/or septic arthritis (SA), are a frequent cause of hospitalization and morbidity in children. In this retrospective observational study, we aim to describe the epidemiology, presentation, and management of children diagnosed with AOI at a Midwest academic healthcare center in central Missouri. Methods Systematically reviewing medical records from July 2015 to March 2021, we identified 73 pediatric patients (age < 18 years) diagnosed with AOI. Cases related to trauma, surgery, or chronic recurrent multifocal osteomyelitis were excluded. Information was collected on clinical course and management, and a descriptive analysis was performed. Results Children meeting the inclusion criteria included 46 males (63%) and a median age at presentation of 6.9 years (IQR 2.8 – 11.9). Presenting symptoms included localized pain (n=72, 99%), refusal to move or bear weight (n=64, 88%) and fever (n=49, 63%); 42 (56%) had all three symptoms. 32 (44%) had OM, 17 (23%) had SA, and 24 (33%) had both; lower extremity long bones/joints were often involved. Definitive bacterial etiology was identified in 49 (67%) patients: 39 (76%) Staphylococcus aureus (16 methicillin resistant [MRSA], 23 methicillin susceptible [MSSA]), 4 (8%) Streptococcus pyogenes, and 3 (6%) Kingella kingae; and blood cultures identified an etiology in 29 of the 69 obtained (42%; 25 MSSA, 2 MRSA, 2 S pyogenes). Surgical management in an operating room was performed in 44 (60%). Median hospitalization was for 5 days (IQR 4-8), and 5 cases (7%) required intensive care, with no mortality. 62 were successfully transitioned from intravenous (IV) antibiotics to oral at discharge (85%) – 10 were discharged with IV antibiotics and one infant received full IV course in hospital. Definitive oral antibiotics used included cephalexin (35), clindamycin (24), and amoxicillin (3). 8 (11%) required hospital readmission for various reasons. Conclusion Our trends in AOI are comparable to those reported nationally – blood cultures remain key in identifying etiology and empiric therapy should continue to target S aureus. Most children can be successfully transitioned to oral antibiotics at discharge. This data will guide us in preparing a clinical pathway at our center. Disclosures All Authors: No reported disclosures.

Background: The MedZou Community Health Clinic at the University of Missouri School of Medicine is a student-run free clinic (SRFC) providing primary care and specialty services to uninsured patients of Missouri. Little is published about the relationship of volunteerism in SRFCs and residency match results. This study evaluated the association of SRFC volunteering on residency placement. We hy-pothesized that there would be an increased likelihood of medical students matching into specialties correlating with specialty clinics they volunteered with as students. Methods: We analyzed data on volunteers who graduated from the University of Missouri School of Medicine between 2010-2019 in this retrospective study. Selection criteria included students who per-mitted publishing their residency match results publicly and actively volunteered for MedZou (at least five volunteer shifts). Odds ratios (OR) were calculated with Fisher exact tests using a confidence in-terval (CI) of 95% to assess whether volunteering in a specialty clinic was associated with matching in that specialty. Clinics with at least five volunteers during the study period were analyzed (Dermatol-ogy, Musculoskeletal [MSK], and Neurology). Results: Twenty-nine percent of the MedZou volunteers that fit the inclusion criteria volunteered for the Dermatology, MSK, or Neurology Clinic. We found significant associations between those who volunteered in a specialty clinic and those who matched in a related specialty for Dermatology (OR = 4.25, 95% CI = 1.37, 12.13), Musculoskeletal (OR = 3.49, 95% CI = 1.45, 7.98), and Neurology Clinics (OR = 10.89, CI = 1.71, 50.39). Additionally, 51% of MedZou volunteers that fit inclusion criteria volunteered for Primary Care Clinic. These students were also found to have a significant association with matching into a related primary care specialty (OR= 2.01, CI= 1.14, 3.62). Conclusions: The results of this study indicated that clinical exposure at a SRFC specialty clinic was associated with residency match into related specialties.

Osteogenesis imperfecta (OI) is a heritable connective tissue disorder with patients exhibiting bone fragility and muscle weakness. The synergistic biochemical and biomechanical relationship between bone and muscle is a critical potential therapeutic target, such that muscle weakness should not be ignored. Previous studies demonstrated mitochondrial dysfunction in the skeletal muscle of oim/oim mice, which model a severe human type III OI. Here, we further characterize this mitochondrial dysfunction and evaluate several parameters of whole body and skeletal muscle metabolism. We demonstrate reduced mitochondrial respiration in female gastrocnemius muscle, but not in liver or heart mitochondria, suggesting that mitochondrial dysfunction is not global in the oim/oim mouse. Myosin heavy chain fiber type distributions were altered in the oim/oim soleus muscle with a decrease (-33 to 50%) in type I myofibers and an increase (+31%) in type IIa myofibers relative to their wildtype (WT) littermates. Additionally, altered body composition and increased energy expenditure were observed oim/oim mice relative to WT littermates. These results suggest that skeletal muscle mitochondrial dysfunction is linked to whole body metabolic alterations and to skeletal muscle weakness in the oim/oim mouse.

Adequate pain management is one of the biggest challenges of the modern healthcare system. Physician perception of patient subjective pain, which is crucial to pain management, is susceptible to a host of potential biases. Here we explore the timing of physicians’ work as a previously unrecognized source of systematic bias in pain management. We hypothesized that during night shifts, sleep deprivation, fatigue, and stress would reduce physicians’ empathy for others’ pain, leading to underprescription of analgesics for patient pain relief. In study 1, 67 resident physicians, either following a night shift or not, performed empathy for pain assessment tasks and simulated patient scenarios in laboratory conditions. As predicted, following a night shift, physicians showed reduced empathy for pain. In study 2, we explored this phenomenon in medical decisions in the field. We analyzed three emergency department datasets from Israel and the United States that included discharge notes of patients arriving with pain complaints during 2013 to 2020 ( n = 13,482). Across all datasets, physicians were less likely to prescribe an analgesic during night shifts (compared to daytime shifts) and prescribed fewer analgesics than generally recommended by the World Health Organization. This effect remained significant after adjusting for patient, physician, type of complaint, and emergency department characteristics. Underprescription for pain during night shifts was particularly prominent for opioids. We conclude that night shift work is an important and previously unrecognized source of bias in pain management, likely stemming from impaired perception of pain. We consider the implications for hospitals and other organizations employing night shifts.

Nocturnal oximetry is an alternative modality for evaluating obstructive sleep apnea syndrome (OSAS) severity when polysomnography is not available. The Oxygen Desaturation (≥3%) Index (ODI3) and McGill Oximetry Score (MOS) are used as predictors of moderate-to-severe OSAS (apnea-hypopnea index-AHI5 episodes/h), an indication for adenotonsillectomy. We hypothesised that ODI3 is a better predictive parameter for AHI5 episodes/h than the MOS. All polysomnograms performed in otherwise healthy, snoring children with tonsillar hypertrophy in a tertiary hospital (November 2014 to May 2019) were analysed. The ODI3 and MOS were derived from the oximetry channel of each polysomnogram. Logistic regression was applied to assess associations of ODI3 or MOS (predictors) with an AHI5 episodes/h (primary outcome). Receiver operating characteristic (ROC) curves and areas under ROC curves were used to compare the ODI3 and MOS as predictors of moderate-to-severe OSAS. The optimal cut-off value for each oximetry parameter was determined using Youden's index. Polysomnograms of 112 children (median [interquartile range] age 6.1 [3.9-9.1] years; 35.7% overweight) were analysed. Moderate-to-severe OSAS prevalence was 49.1%. The ODI3 and MOS were significant predictors of moderate-to-severe OSAS after adjustment for overweight, sex, and age (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.19-1.51); and OR 4.10, 95% CI 2.06-8.15, respectively; p 0.001 for both). Area under the ROC curve was higher for the ODI3 than for MOS (0.903 [95% CI 0.842-0.964] versus 0.745 [95% CI 0.668-0.821]; p 0.001). Optimal cut-off values for the ODI3 and MOS were ≥4.3 episodes/h and ≥2, respectively. The ODI3 emerges as preferable or at least a complementary oximetry parameter to MOS for detecting moderate-to-severe OSAS in snoring children when polysomnography is not available.

Background A parent survey was conducted to assess the sleep habits of children residing in various countries before and during the SARS‐CoV‐2 pandemic. It was hypothesized that lockdown would be associated with increased sleep duration. Methods Outcomes were changes in bedtime, wake time, and sleep duration in the pandemic compared to before. Logistic regression was applied to evaluate the effects of age and covariates on outcomes. Results A total of 845 questionnaires completed from May 1 to June 10, 2020 were analyzed (45.8% female; age 3–17 years). During the pandemic, 23.1% of preschoolers, 46.2% of school‐age children, and 89.8% of adolescents were going to bed after 10 p.m. on weekdays compared to 7.1%, 9.4%, and 57.1% respectively before the pandemic, with these proportions being higher on weekends. Likewise, 42.5% of preschoolers, 61.3% of school‐age children, and 81.2% of adolescents were waking after 8 a.m. on weekdays (11.6%, 4.9%, and 10.3%, before) with these proportions being greater on weekends. Sleep duration did not change in 43% of participants on weekdays and in 46.2% on weekends. The 14–17 years group had fourfold increased odds for longer sleep duration on weekdays (p

Objective This study aimed to assess neonatologists' experience and comfort with neonatal electrical cardioversion or defibrillation (EC-D). Study design Electronic surveys were distributed to academic neonatologists affiliated with 12 Midwest academic hospitals. Neonatologists were asked about their residency training; years since completing residency; current certification/competency training in the Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), Advanced Cardiovascular Life Support (ACLS), and Neonatal Resuscitation Program (NRP); experiences with EC-D; availability of a pediatric cardiologist; and their comfort levels with such procedures. Standard statistical tests evaluated comfort with EC-D. Results Seventy-two out of 180 neonatologists responded to the survey (response rate = 40%). Of them, 98.6% (71), 54.2% (39), and 37.5% (27) maintained current NRP, BLS, and PALS trainings, respectively. Also, 73.6% (n = 53) reported having performed neonatal EC-D. Of those, 50.9% (n = 27) indicated feeling slightly to very uncomfortable performing EC-D. We report a lack of BLS certification being associated with a lack of comfort (odds ratio [OR]: 0.269, 95% confidence interval [CI]: [0.071, 0.936]), and a positive association between a pediatric cardiologist being present and being uncomfortable (OR: 3.722, 95% CI: [1.069, 14.059]). Those reporting greater volume and more recent experience with EC-D report more comfort. Conclusion Of neonatologists who performed EC-D, half of them reported being uncomfortable. BLS certification and experience are positively associated with comfort in performing EC-D. Simulations to increase training in EC-D should be offered regularly to academic neonatologists. Key points · Most neonatologists have performed EC-D, but many feel uncomfortable with performing EC-D.. · Many do not maintain current certification in BLS, PALS, or ACLS.. · Simulation training in EC-D will increase comfort with EC-D..

Background: Our level III neonatal intensive care unit (NICU) implemented the use of an exclusive human milk diet (EHD) and sought to determine its effect on the severe co-morbidities of preterm in...

Rationale: Although sleep disordered breathing (SDB) may increase urinary albumin excretion (UAE) by raising nocturnal blood pressure (BP) in addition to diurnal BP, the correlation has not been in...

BACKGROUND: Atrial flutter and life-threatening ventricular arrhythmias are rare in neonates1. Atrial flutter may require cardioversion while ventricular tachycardia may deteriorate into pulseless cardiac arrest requiring defibrillation. Neonatologists are trained in Neonatal Resuscitation Program (NRP) that does not include training on cardioversion or defibrillation. This study surveyed neonatologists on their experiences and comfort with cardioversions and defibrillation. METHODS: The project was approved by the human research protection office at the University of Missouri in Columbia, Missouri. We distributed an electronic survery …

Background In the midst of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, a lot more chaos could be anticipated in the flu season due to the coexistence of SARS-CoV-2 and influenza with almost similar epidemiologic and clinical features. Could this become a "twindemic" or “syndemic” if there is any viral interference occurs? We investigated the effect of influenza and pneumococcal vaccines on the disease course of SARS-CoV-2 in the pediatric population and the possibility of viral interference. Material and methods After approval from Institutional Review Board, a retrospective electronic chart review on 20 years and younger SARS-CoV-2 polymerase chain reaction (PCR) positive patients who visited Arkansas Children’s Hospital System between February 1 to August 30, 2020, was performed. The clinical data was collected along with influenza and pneumococcal vaccination status of these patients. Results The results showed that viral interference may have played a role in the current flu and coronavirus disease 2019 (COVID-19) twindemic. SARS-CoV-2 and influenza may have significantly affected each other’s epidemiological features. Conclusion Understanding the relationship and co-existence of other viruses alongside SARS-CoV-2 and knowing the vaccination status of the host population may help in deploying the right strategies to get the best outcomes.

Energy Star (ES) appliances are required to provide the same features and performance as their unlabeled counterparts, but do so with increased efficiency. However, the expected energy savings from such labeling may not be as great as expected. This paper contributes to previous research on ES labeling by examining household behavior and electricity consumption. Using two different household surveys on energy use, we provide a first attempt to estimate the impact of ES appliance ownership on actual household electricity usage. The results show a significant effect for ES refrigerators reducing electricity use, while the analysis for ES televisions suggests an increase in electricity usage by LCD TV owners. The findings highlight the need for more research on household energy consumption and the efficacy of the ES appliance program.

A major concern with electricity market restructuring has been the possibility that fuel price volatility may leak into electricity prices. This view is credible if electricity price – fuel costs relation is stronger in restructured than in non-restructured states. We examine the validity of this view using panel data on for industrial, residential and commercial sectors in US states. The analysis accounts for cross-sectional dependency, cross-state heterogeneity, and interdependency of state fuel markets. The common correlated effects mean-group estimates suggest that (1) coal and natural gas costs Granger-cause electricity prices for industrial and commercial customers in both non-restructured and restructured states; (2) both fuel costs also Granger-cause electricity prices for residential customers in non-restructured states but only natural gas costs cause electricity prices in restructured states; (3) the long-run impacts of fuel costs on electricity prices are higher in non-restructured than restructured states; and (4) electricity prices exhibit lower persistence in non-restructured than in restructured states. These results are do not support the view of higher integration between input costs and electricity prices in restructured markets. Policymakers should be aware of the differences in electricity price response in alternative market structures when implementing new federal policies.

Building block 3 of the Clean Power Plan sets a target for increasing renewable generation. Using the AVERT model created by the EPA, emissions reductions can be estimated for each state. Comparing these estimates to the target rate highlights the importance of the mass- and rate-based targets. The results also highlight the usefulness of the AVERT program to study renewable energy and energy efficiency policy, and retirements and additions to the fossil fuel fleet, as well as the limitations of the AVERT model in examining the current constraints of developing renewable energy.

Electricity consumption produces private goods, such as heat for homes, but fossil fuel consumption impacts the public goods of clean air and water. While self interests can increase usage, social interests, such as global climate change, can impact an individual's attitude toward energy consumption. This paper examines the tragedy of the commons using household data, and compares the impact of self and social interests in predicting electricity consumption. Using both stated and observed behavioral data, the results show that self interests have a greater impact on energy saving behaviors and electricity use. We extend the analysis to control for an individual's environmental concern and perceived behavioral impact, finding similar results, and supporting the notion that the tragedy of the commons occurs regardless of a person's perception or environmental concern. These findings may explain why pro-environmental attitudes do not necessarily lead to pro-environmental behaviors, and it contributes to our understanding of the motivating factors for energy savings and electricity use by examining both stated and observed behaviors. Policies aimed at electricity reduction may have a greater impact if they focus on private interests, such as pricing, rebates, subsidies, and taxes, rather than social interests alone.

This paper examines the causal relationship between economic growth and electricity generation from renewable sources (biomass, geothermal, hydroelectric, solar, waste, and wind) across 20 OECD countries over 1990 to 2008. The results from a commonly used panel error correction model find (a) a bidirectional relationship between aggregate renewable generation and real GDP, (b) biomass, hydroelectricity, waste, and wind energy exhibit a positive long-run relationship with GDP, (c) hydroelectricity and waste generation exhibit a short-run positive bidirectional relationship with GDP growth, and (d) biomass, hydroelectric, and waste electricity generation have the largest impact on real GDP in the long-run. We extend the analysis to consider the possibility of structural breaks and cross-sectional dependence. Accounting for cross-sectional dependence, we find that in the short-run, increases in biomass and waste generation negatively affect GDP, while aggregate renewable and hydroelectricity increase GDP. Energy conservation policies will positively impact GDP, if the policies cause decreases in biomass or waste energy but increase hydroelectricity and wind energy.

We examine a type of lottery used to distribute some publicly held resource access rights. The lottery provides participants with the opportunity to choose among a set of simple gambles over multi-attribute goods. Participant choices result in an endogenous distribution of success rates over gambles that reflects tradeoffs between the relative desirability of the available goods and the probability of winning. When lottery winnings are multi-attribute goods, lottery outcomes provide sufficient information to estimate hedonic prices, marginal utility, and marginal rates of substitution among attributes. We develop a model for characterizing preferences from this information set. We apply our model to Idaho׳s Four Rivers Whitewater Recreation Lottery, which allows applicants to apply for one permit among a large set of alternative river/day combinations that provide varying river and weather characteristics. This lottery structure shows promise as a foundation for economic experiments for preference revelation.

The rights to use publicly-managed natural resources are sometimes distributed by lottery, and typically these rights are nontransferable. Prohibition of post-lottery permit transfers discourages applicants from entering the lottery solely for profitable permit sale, so only those who personally value the use of the resource apply. However, because permits are distributed randomly and trade is restricted, permits may not be used by those who value them most. We argue that restrictions on permit transfers is a policy response designed to limit entry when interest group membership is not distinguishable ex ante, and characterize the economic/informational conditions under which post-lottery prohibitions on trade are likely to arise. We develop our model using the specific case of the Four Rivers Lottery used to allocate rafting permits on four river sections in Idaho.

Traditional electric utility companies face a trade-off between building generation facilities that utilize renewable energy (RE) and non-renewable energy (non-RE). The firm's input decision to build capacity for either source depends on several constraining factors, including input prices, policies that promote or discourage RE use, and the type of regulation faced by the firm. This paper models the utility company's decision between RE and non-RE capital inputs. From the model, we derive the result that rate-of-return (ROR) regulation decreases the investment in RE capital relative to the unregulated firm. These findings suggest restructuring electricity generation markets, which removes the ROR on generating assets, can increase the relative use of RE. A second result of the model shows that the renewable portfolio standard (RPS) increases the investment in capital that requires RE as a source of electricity, as expected. This paper contributes to the literature on the substitution between renewable and non-renewable resources, by examining the policies that affect the investment in the two types of technologies. The model can also be applied to other regulated utilities, such as water or natural gas companies, with outputs that are produced from different types of capital.

I. INTRODUCTION Prescription drugs are almost ideal examples of homogeneous commodities. A patient can fill her prescription at any pharmacy she chooses and expect to obtain exactly the same medicine. A priori, therefore, it would seem that if any commodity obeyed the law of one price then a prescription drug would be that commodity. That is not the case. Using data from two townships in up-state New York, Sorensen (2000) provided compelling evidence that the prices of individual drugs varied substantially among pharmacies within each of the two communities. The extent of price dispersion differed among individual drugs in ways that were consistent with the predictions of models that explain price dispersion on the basis of costly consumer search. Price dispersion among homogeneous goods is not unique. Other studies have examined the determinants of price dispersion in the markets for gasoline (Adams 1997), water (Yoskowitz 2002), automobiles (Dahlby and West 1986; Goldberg and Verboven 2001), grocery products (Aalto-Setala 2003), mutual funds (Hortacsu and Syverson 2004), Internet and retail sales of books and CDs (Brynjolfsson and Smith 2000), and several different products (Pratt, Wise, and Zeckhauser 1979). They have also generally concluded that prices in those markets vary in ways that cannot be accounted for solely by heterogeneity in product attributes with respect to physical characteristics, space, time, or, in cross-country studies, government regulation. In addition, apparent violations of the law of one price have been observed in commodity markets for agricultural products and raw materials that are relatively homogeneous with respect to their physical characteristics (see. e.g., Goodwin, Grennes, and Wohlgenant 1990). However, Sorensen's study of pharmaceutical drugs is of particular interest because he examines prices in two clearly defined markets for commodities that are physically identical. He finds that search costs, measured by the frequency of drug purchases, affect the amount of price dispersion. Models of price dispersion based on costly search for information by consumers seem to provide plausible alternative explanations, especially as many prescription drugs are not widely used and their prices are not commonly known by buyers. As Sorensen observes, his empirical analysis of the effects of search costs is incomplete in at least one important respect. Sorensen's data were for only two geographically adjacent markets (less than 30 miles apart). Thus, he could not investigate the effects of characteristics of the communities being served by the pharmacies in those markets. In this article, we address the question, "who searches for the lowest drug prices?" Research by Talukdar (2008) and Morton, Zettelmeyer, and Silva-Risso (2003) show a link between consumer search characteristics and retail and Internet pricing. Thus, search characteristics for consumer groups may be very different across drug markets as well. For example, the proportions of the elderly and the poor in a population served by a market may affect the amount of search in that market because of differences in opportunity costs of time and expected benefits from search. We expand upon previous research to examine market characteristics that affect price dispersion among prescription drugs. Our analysis of consumer search characteristics is particularly relevant to the current policy debate concerning healthcare reform, changes to Medicare, and insurance coverage through the workplace. We examine price dispersion for pharmaceutical drugs in five geographically isolated markets in Montana using data obtained from a cross-section survey, administered by the authors on the pricing of 75 different drugs by individual pharmacies. The five markets are a minimum of 80 miles apart from one another and have distinctly different demographic and other socioeconomic characteristics. The new data set permits a more extensive evaluation of the effects of search and population characteristics on price dispersion. …

Indirect impacts associated with Illinois’ RPS include a change in the laws concerning the planning and zoning for wind development, a market for renewable energy credits, and awareness of problems with the transmission grid.

This paper studies the development of renewable energy (RE) in the U.S. by examining the capacity to generate electricity from renewable sources. RE capacity exhibits a U-shaped relationship with per capita income, similar to other metrics for environmental quality (EQ). To explain this phenomenon, I consider several of the environmental Kuznets curve theories that describe the relationship between income and environmental quality (Y-EQ), including evolving property rights, increased demand for improved EQ, and changing economic composition. The results fail to provide support for the Y-EQ theories. I further consider the alternative hypothesis that increases in unemployment lead to increases in relative RE capacity, suggesting that promoting RE projects as a potential job creator is one of the main drivers of RE projects. The results imply that lagged unemployment is a significant predictor of relative RE capacity, particularly for states with a large manufacturing share of GDP.