The constantly increasing measures of sanctions impact contribute to advancing development of political conflict of Russia with unfriendly countries, that results in increasing economic pressure on sectors of the Russian consumer market that are the most import-dependent ones. Currently, the European Union, the United States, Japan and other states that received status of unfriendly ones, are actively applying secondary sanctions originally developed as tool to curb schemes of circumventing existing bans against Russia, of which legalization of parallel imports, introduced in 2022, was among the most effective ones. By their content, secondary sanctions imply possibility of imposing prohibitive measures on foreign counter-agents from countries that are friendly for Russia, that cause additional difficulties with registration, making payments and increased delivery time. Of course, all the circumstances mentioned above could not help but affect export and re-export of medical devices to Russia. The detailed analysis of content of imposed sanctions measures established that currently there are no direct bans on export and re-export of medical equipment, as well as components and consumables, parts and accessories. The only exception are medical devices classified as dual-use goods and fairly large number of complex technological equipment, including its components, that fell under measures of strengthening export control imposed by the United States. Despite the fact that there are no formal sanctions against medical equipment and articles, in practice they are actively used, and given absence of unified methodology, issue of their implementation becomes even more ambiguous and problematic that makes the topic under consideration relevant. The article examines in detail main content of the prohibitive and restrictive measures taken within the framework of the sanctions impact from unfriendly states in relation to export and re-export of specialized medical equipment and components. Also are considered the listing of goods classified as of dual-use in terms of medical devices. The detailed list of medical products for which the US requirement to issue an export license for their export applies is presented. The practical recommendations are formulated to address main problematic issues.

Systematic review. The purpose of this study was to assess the cost-effectiveness of surgery for spinal metastasis therapy. The optimal treatment for many cases of spinal metastasis (SM) is surgery followed by adjuvant radiotherapy (RT). However, the cost-effectiveness of combined therapy (CT; surgery and RT) is unclear due to the short median survival time among SM patients and the higher costs of combined therapy compared with RT alone. We performed a systematic literature search from inception to January 21, 2024. We included studies that reported on the cost-effectiveness of surgical intervention for SM and assessed their quality using the Quality of Health Economic Studies instrument. We identified 5024 studies of which eight met our inclusion. All included studies were of fair to high quality. Of the seven studies that compared CT to definitive RT, six concluded that CT was cost-effective. Of note, one of the studies concluding that CT was cost-effective, only found CT to be cost-effective when considering patients with a three-month survival probability above 50%. An additional study compared their calculated Incremental Cost-Effectiveness Ratio (ICER) value to the standard Willingness to Pay (WTP) threshold in Thailand and concluded that CT was not cost-effective in Thailand. After comparing their reported ICER value to a commonly used WTP in the United States, we found CT to be cost-effective. We found CT consisting of surgery and RT to be cost effective in six out of seven (85.7%) studies. Cost effectiveness might be even more pronounced in certain patient subgroups, such as patients with a high predicted survival. However, most studies did not report therapy details, a factor which could greatly influence cost-effectiveness.

We tested an adaptation of a mobile HIV prevention smartphone app, HealthMindr-PrEP, to assess its effectiveness to increase pre-exposure prophylaxis (PrEP) uptake among gay and bisexual men who have sex with men. This study was conducted online among gay and bisexual men who have sex with men living in Ending the HIV Epidemic priority jurisdictions, primarily in the southern United States. We conducted a randomized controlled trial in which participants were randomly assigned to receive the intervention app or an app that only allowed participants to track their study progress. The primary outcome was self-reported PrEP uptake. Cox proportional hazards models were used to compare the rate of PrEP uptake across study arms. Although no results were statistically significant, the rate of PrEP initiation was higher among participants in the intervention arm compared with the control arm, particularly among participants with PrEP indications at baseline. Among those with PrEP indications at baseline, participants in the intervention arm had a 64% higher rate of PrEP initiation compared with the control arm (hazard ratio = 1.64, 95% CI: 0.89 to 3.03). Among those without PrEP indications, the same hazard ratio was 1.05 (95% CI: 0.67 to 1.66). Our results suggest that HealthMindr-PrEP increases the rate of PrEP uptake compared with a standard of care control condition; however, we had insufficient statistical power for stratified analyses that demonstrated that the strongest effect was among those who had PrEP indications at baseline.

Patient journey in generalized myasthenia gravis in the United States: Barriers to timely diagnosis and proposed solutions.

Comparative Outcomes and Cardiac Imaging Features in Light Chain Versus Transthyretin Cardiac Amyloidosis: A Multicenter Retrospective Cohort Study.

The HIV epidemic in the United States disproportionately affects sexual and gender minority (SGM) communities. Social networks shape health behaviors. Understanding the structure and dynamics of SGM networks could enhance engagement with HIV-related services. We analyzed egocentric social networks of SGM individuals in Charlotte, North Carolina, who engaged in HIV-related services. Participants (egos) identified social connections (alters) from the past 6 months. Networks were stratified based on the size of the ego's sexual network (0-1 vs. ≥2), defined as the subset of alters with reported sexual partnerships, to assess differences in structure and support dynamics. Among 51 participants, 294 alters were reported. Networks with 0-1 sexual partners were smaller, more connected, and exhibited greater demographic diversity. These egos had stronger ties with their alters (n = 141), who were more likely to provide social and health-related support. By contrast, networks with ≥2 sexual partners (n = 153 alters) were less cohesive, exhibited lower network density and global efficiency (capacity for efficient information sharing), and sexual partners were less likely to offer health support. Network-based interventions must account for pre-existing social support structures. Tight-knit, supportive networks may reinforce health norms and serve as conduits for intervention messaging, while individuals with larger, less connected sexual networks may require additional support to mobilize their networks effectively. Tailoring interventions to network dynamics could enhance HIV service uptake and improve health outcomes in SGM populations.

Racism and racial terrorism are still prevalent in the United States (US). This article relates the experience of a multi-ethnic faith community in the American South that read together the Book of Esther to improve race relations. Based on a contextual Bible study (CBS) methodology, the Scripture was read with cultural and contextual sensitivity and hermeneutical creativity for racial justice, racial reconciliation, and racial unity. By reading Scripture with a diversity of people, individual biases and presuppositions were exposed and challenged, and new, rich insights were revealed and ascertained. Racial justice, reconciliation, and unity take a commitment to the regular study of Scripture and society, engagement in the public domain, and the church. Contribution: The article intersects the biblical scholarship of Esther with the CBS of the scriptural novella in the American South, and with intercultural hermeneutics, vis-à-vis historically fraught race-relations – the fusion and dynamism of which bolster the local multi-ethnic faith community toward reconciliation and unity.

To determine population attributable fractions (PAFs) of modifiable dementia risk factors by income, and independent and interactive associations of race-ethnicity and income with each risk factor and cumulative number of midlife risk factors. This nationally representative cross-sectional study of the 1999-2008, 2011-2014, and primarily the 2015-2018 National Health and Nutrition Examination Surveys comprised of individuals aged 18-44, 45-64, and 65+ years for early-life, midlife, and late-life analyses, respectively. Income was operationalized using the poverty-income ratio. The primary outcomes were PAFs and prevalence ratios (PR) of the 13 individual-level dementia risk factors and cumulative number of midlife risk factors. There were 13,145 individuals with risk factor data between 2015 and 2018 (51.1% aged 18-44, 31.0% aged 45-64, and 17.9% aged ≥65 years; 51.5% female after survey-weighting). Higher income was associated with lower prevalence of each dementia risk factor except obesity, high LDL, and TBI. The highest PAF for those with incomes <100% of the federal poverty level was late-life vision loss (20.9%, 95% CI 16.8%-25.2%). Higher income was associated with lower number of midlife risk factors (PR: 0.91, 95% CI 0.89-0.94). Race-ethnicity categories historically-underrepresented in dementia studies were associated with midlife diabetes, obesity, physical inactivity, and late-life vision loss. Lower income and historically underrepresented race-ethnicity categories are associated with many dementia risk factors. Dementia prevention efforts may be more successful by targeting modifiable risk factors in these higher-risk populations.

Association of Lp(a) With Cardiovascular Disease and All-Cause Mortality in U.S. Hispanics and Latinos.

Phakopsora pachyrhizi, the causal agent of soybean rust disease (SBR) on Glycine max (soybean), is considered one of the most globally devastating diseases of soybeans and is a particular problem in Brazil, China, Sub-Saharan Africa, and the southern United States. To better understand genetic diversity and epidemiological history of SBR in the United States, 49 P. pachyrhizi isolates collected from soybean fields in four Southeastern states (Alabama, Florida, Georgia, and Louisiana) from the 2008 to 2017 growing seasons were genotyped through restriction site-associated genotype by sequencing (GBS). Rarefaction analysis identified 54 informative SNPs among the P. pachyrhizi isolates. We found no evidence suggesting sexual or parasexual recombination, and measurements of genetic diversity were low to moderately low. Multiple different statistical approaches, including neighbor-joining trees, K-means hierarchical clustering, discriminant analysis of principal components, and principal coordinates analysis (PCoA) all identified two groups of P. pachyrhizi genotypes that associated with geographic location. One group was composed of isolates from south Georgia, and the other with isolates from Alabama, Florida, Georgia (excluding south Georgia), and Louisiana. Our results suggest that two genetically related but distinct genotypes were introduced to the continental United States in a two-phase introduction and overwinter in South Georgia and Florida. The first introduction of one genotype likely occurred in South Georgia in 2004 followed by a later introduction of a second genotype. One genotype remained in South Georgia while the other genotype became established through the Southeastern United States. Future studies are necessary to determine whether SBR in Brazil, China, or Sub-Saharan Africa shows similar patterns of genotype distribution and history or if the United States situation is unique.

Despite advances in HIV treatment, disparities in healthcare access remain across low-income (LIC), middle-income (MIC), and high-income (HIC) countries, limiting access to clinical care, antiretroviral therapy, and viral load testing. This study developed the HIV Care Access Index (HIV-CAI) to measure and compare HIV care service access across countries and within geographic regions and examined associations with economic and health indicators. A cross-sectional survey was conducted between August 2021 and June 2023 across nine countries: Botswana, China, Colombia, Kenya, Nigeria, Puerto Rico, South Africa, Thailand, and the United States. Participants were adults living with HIV recruited from urban, suburban, and rural settings through HIV service organizations, sexual and gender minority centers, and resource-limited communities. The HIV-CAI was scored from 0 to 1 (worst to best access) across three domains: Access to HIV Clinical Care and Providers, Access to HIV Medication, and Access to Viral Load Testing. Among 1,598 participants, Botswana demonstrated the highest HIV care access (0.93), followed by Thailand (0.91) and Kenya (0.90), while Nigeria showed the lowest access (0.64). Access to HIV medication was relatively consistent across regions, whereas access to clinical care and providers was limited, particularly in rural areas. Countries with higher HIV burden, incidence, and prevalence were associated with better care access. The HIV-CAI reveals disparities in HIV care access across geographic areas. Future interventions should prioritize improving equitable access, particularly in rural areas and countries with lower overall access scores.

Purpose As tourist misbehavior becomes increasingly disruptive in many destinations, there is a growing need to identify the factors that influence such behavior. Recognizing that individual psychological differences affect behavior in distinct ways, this study examines the role of psychological entitlement in contributing to moral disengagement at tourist destinations. Design/methodology/approach The survey targeted individuals residing in the United States. Data were collected through an online crowdsourcing platform. A total of 565 responses were included in the analyses, which comprised confirmatory factor analysis, structural equation modeling, and moderation analysis. Findings The findings of this study suggest that individual entitlement is significantly associated with a person’s moral disengagement. Entitled individuals tend to judge a destination in a more negative manner, which influences their moral disengagement. An individual’s perceived familiarity with a destination plays a moderating role in these relationships. Practical implications This study integrates psychological entitlement, destination emotions and moral disengagement, demonstrating how individual psychology drives emotional states toward a destination and influences moral disengagement in the context of international tourism. Destination managers should attempt to reduce visitors’ psychological entitlement and potential misbehavior through clear messages emphasizing the disadvantages or consequences that individuals may encounter. Originality/value This study addresses psychological entitlement as a critical yet overlooked antecedent of tourist misbehavior, moving beyond situational explanations to highlight a psychological trait that predisposes individuals to unethical behavior while traveling. It also extends moral disengagement theory into the tourism domain by demonstrating how entitled tourists rationalize their misbehavior. In addition, by identifying destination familiarity as a boundary condition, the study explores how entitlement is most likely to translate into negative affect and disengagement.

Nontuberculous mycobacteria (NTM) are a group of environmental bacteria that encompass nearly 200 described species, some of which can cause chronic pulmonary and extrapulmonary infections in humans. What makes these infections unique is that they are environmentally acquired, yet there remains a limited understanding of how different environments contribute to potential pathogen exposure. Here, we use new and existing marker gene data sets to compare the amounts and types of NTM across three environments known to harbor mycobacteria, surface waters, soil, and household plumbing biofilms, to better understand potential pathogen occurrence in each environment. We used 16S rRNA gene sequencing, in tandem with mycobacterial-specific marker gene sequencing, to characterize variation in the relative abundances of the genus Mycobacterium and specific mycobacterial taxa across the three environments, with a focus on a clinically significant NTM. We found that household plumbing biofilms contained both the highest relative abundance of the genus Mycobacterium (on average, 13.7% of bacteria were members of the genus), as well as the highest occurrence of clinically relevant species detected (Mycobacterium avium and Mycobacterium abscessus), compared to surface waters and soil. Although mycobacteria are ubiquitous across many different environments, mycobacterial diversity is highly variable between environments with clinically relevant species largely restricted to household plumbing biofilms, information that is critical for understanding the ecology and epidemiology of NTM disease.IMPORTANCENontuberculous mycobacteria, or NTM, are a diverse group of bacteria within the genus Mycobacterium that are common in many environments. While most members of the genus pose little threat to human health, a handful of species, namely the Mycobacterium avium complex, M. abscessus, and M. kansasii, can cause severe and prolonged lung infections. These environmentally acquired infections are on the rise in the United States and around the world, yet we still do not have a good understanding of which environment types pose the greatest risk of infection to susceptible populations. Our study used cultivation-independent approaches to identify the specific NTM taxa found in over 1,000 samples from three potentially important environmental reservoirs-surface waters, soils, and household plumbing systems, to determine which of these environments are most likely to harbor NTM of clinical significance. Our results highlight the high degree of variability in the types of NTM taxa detected in different environments (including extensive novel diversity within the genus) and show that household plumbing biofilms are likely the most important reservoir and subsequent route of transmission for clinically significant NTM.

The ASHP Pharmacy Forecast 2026 is written to identify and contextualize emerging trends that will influence healthcare, health systems, and the pharmacy profession. It provides recommendations to inform strategic planning that should prompt action by pharmacists and health-system leaders. Drawing on "the wisdom of crowds" concept, a survey was constructed by an advisory committee with 6 themes, each with 7 focused statements and a seventh theme on preparedness (54 survey items in total). A survey panel of 383 pharmacy leaders was purposefully designed to capture opinions from a wide range of pharmacists across the United States. Panelists were asked to consider the likelihood of the statements occurring in the next 5 years as being likely, somewhat likely, somewhat unlikely, or very unlikely. Forecast panelists also assessed health systems' preparedness (from very unprepared to very prepared) for 12 of the statements. The 6 survey themes identified were Policy, Drug Costs, and the Financial Stability of Health Systems; Stabilizing the Pharmaceutical Supply Chain; Patients as Consumers of Health Care; Realizing the Potential of Therapeutic Advances; Environmental Sustainability and Resilience; and Transforming Safety. The survey was completed by 298 respondents, yielding a 78% response rate. Descriptive statistics of the survey results were provided to chapter authors to inform commentary with strategic recommendations for each theme. The Pharmacy Forecast provides insights into large-scale, long-term trends that will influence healthcare and the pharmacy profession over the years ahead. Insights from the report can stimulate strategic thinking and provide a starting point to proactively position leaders, their teams, and departments for potential future trends.

The expansion of haemophilia treatment to include non-factor prophylaxis provides new options with various benefits, risks, administration modes, and device types, necessitating trade-offs in decision-making. This study evaluated prophylactic treatment preferences of people with haemophilia and their caregivers, assessing their willingness to make trade-offs among treatment attributes. A web-based survey containing a discrete-choice experiment (DCE) was completed by adults (≥ 18 years old) and caregivers of children (aged 8-17 years) with haemophilia in the United States and United Kingdom. Participants were asked to complete 10 choice tasks, choosing their preferred prophylaxis from two hypothetical profiles defined by seven attributes. The primary analysis employed a mixed logit model, and subgroup analyses explored preference heterogeneity. Participants were 194 adults with haemophilia (US: 150; UK: 44) and 169 caregivers (US: 150; UK: 19). Avoiding daily treatment administration had the highest attribute importance among both adults and caregivers, followed by changes in annual bleeds. Participants were willing to accept an increased risk of serious side effects or developing inhibitors, or reduced efficacy in preventing annual bleeds, to switch from intravenous to subcutaneous administration. Refrigeration requirements and the need for a second treatment for breakthrough bleeds had lower importance. Participants highly value avoiding daily administration and reducing bleeds, and they are willing to accept increased risks or reduced efficacy to have subcutaneous rather than intravenous administration. As new treatments become available, understanding these preferences can facilitate shared decision-making in treatment selection and enhance patient-centred drug development and patient communication.

Streptomyces bacteria play key ecological and functional roles in terrestrial ecosystems. We surveyed soil samples across the continental United States, identifying six novel Streptomyces species. Here, we report the whole genome sequences of these strains and their predicted biosynthetic products, providing additional information for studying biological and chemical diversity in this ubiquitous species.

Considerable variation exists across societies in the prevalence of demographic trends associated with the second demographic transition (SDT). We propose that these persistent disparities are, in part, determined by long-standing cultural traits. Employing an epidemiological approach, we proxy the inherited component of five key values-gender egalitarianism, religiosity, institutional distrust, generalized trust, and family ties-from the descendants of immigrants in the United States, and link them to SDT outcomes across 23 countries. Our analysis investigates whether societies pre-exposed to these specific values through intergenerational transmission are more or less likely to exhibit SDT, operationalized here as the share of births outside marriage. Our findings reveal that several of these traits exert a notable influence when interacting with educational expansion. Gender egalitarianism, institutional distrust, and generalized trust exhibit positive associations with non-marital birth rates when coupled with increased education. Meaning that, with the broad educational expansion that has taken place across all Western countries after the IIWW, the SDT spreads much faster in societies where these three inherited values are deeply ingrained. Conversely, family ties demonstrate a negative association, while no strong evidence is found regarding the influence of religiosity. In conclusion, our study underscores the necessity of a nuanced cultural approach to the SDT framework, acknowledging the importance of local values alongside the global ideational shift.

Science mapping of root ecology: a bibliometric review covering 2015-2024.

Introduction Marfan syndrome, an inheritable connective tissue disorder, engenders multifaceted systemic effects, impacting the musculoskeletal, ocular, cardiovascular, neurological, cutaneous, and respiratory systems. Its prevalence ranges from 1 : 5000 to 1 : 10,000 individuals, with approximately 25% of cases attributed to spontaneous genetic mutations. In the United States, an estimated 50,000 individuals are affected, and an additional 200,000 individuals exhibit related connective tissue disorders. Aim Here, we present a compelling case of a young soldier who enlisted in our Military Training Center, wherein a previously undiagnosed Marfan syndrome came to light. Case study Notably, a strong family history of the syndrome was evident. Clinical manifestations included pectus excavatum necessitating surgical intervention, an upper-to-lower segment ratio (ULSR) less than 0.86, a span-to-height ratio exceeding 1.05, wrist and thumb signs, scoliosis exceeding 20°, and mitral valve prolapse. Notably, no clinical anomalies about the patient's pulmonary or cutaneous systems were detected. Results and discussion While considerable advancements have been made in comprehending the pathogenesis, the diagnostic protocol for Marfan syndrome remains rooted in the Ghent criteria, mandating a thorough evaluation of multiple organ systems. Conclusions Consequently, the patient was deemed unsuitable for Special Forces deployment and was enlisted as an auxiliary service member, overseen by the Medical Department of the Military Center. Post-discharge, we strongly advocate routine follow-up visits with a family physician to ensure comprehensive medical surveillance.

Effective communication is crucial in perioperative healthcare settings. However, language barriers hinder this communication. In the United States, 8% of individuals over age 5 have a non-English language preference (NELP). Lack of language concordance between patients and healthcare clinicians has been linked to poorer healthcare metrics and outcomes. Despite these challenges, limited research has focused specifically on language barriers in perioperative settings, and few studies have captured experiential data from both caregivers and clinicians. This study aimed to explore whether language discordance between clinicians and caregivers is associated with lower perceived quality of care by either caregivers or clinicians. We also explored whether the interpreting modality impacts perceptions of care by either caregivers or clinicians. This study employed a mixed-methods approach, composed of 9-item 5-point Likert scale questionnaires and explanatory sequential semi-structured interviews of caregivers and clinicians in a large academic medical center. We analyzed caregiver quantitative data using a Mann-Whitney U test. Interview transcripts from caregivers and clinicians underwent thematic analysis. The caregiver and clinician participant response rates were 60% and 69%, respectively. Analysis of caregiver surveys revealed no significant differences between NELP and ELP caregiver responses. Clinician survey analysis revealed significant discrepancies between awareness of interpretation services and true availability of these services in perioperative areas. Major themes identified in caregiver interviews included informational quality, trust, perceived understanding, and overall satisfaction. Major themes identified in clinician interviews included communication barriers, system improvement suggestions, and communication facilitators. This study underscores the importance of preoperative patient/caregiver education to ensure adequate comprehension and understanding in the perioperative setting, particularly within NELP populations. Additionally, the results suggest that in-person interpretation services may improve patient and clinician satisfaction.