Disasters affect the well‐being of individuals, families and communities. Health and social care providers are essential in response and recovery efforts and are among the most vulnerable to negative physical and mental health impacts of a disaster. Few evidence‐based interventions are available to address the psychological needs of providers. The aim of this study was to examine the psychological distress of health and social care providers before and after participating in the brief group intervention, Resilience and Coping for the Healthcare Community (RCHC) and its expanded version, RCHC+. We conducted a pragmatic non‐randomised cluster trial with 762 health and social care providers in south Texas and Puerto Rico post‐Hurricanes Harvey and Maria. Participants completed surveys assessing post‐traumatic stress (PTSD), anxiety, burnout and secondary traumatic stress (STS) prior to intervention delivery and at two time points post‐intervention. We calculated the frequency of symptom cut‐off scores at baseline, then estimated multilevel ordinal models to examine changes in symptoms across time. Prior to participation in the RCHC (approximately 12 months after the hurricanes), providers reported high levels of PTSD, anxiety and STS symptoms. After participation, providers in both intervention conditions reported a significant reduction in PTSD symptoms from baseline that was sustained over both time points. The likelihood of a reduction in symptoms of anxiety and STS from baseline was sustained at both time points for participants in the RCHC+ condition. These findings indicate that both the RCHC and RCHC+ interventions may reduce psychological distress for health and social care providers and could be an important part of advance planning to support provider's mental health during and after a disaster. Further examination of the RCHC in other disaster contexts could provide additional insight into the responsiveness of the intervention to reducing psychological distress symptoms. Health and social care providers are essential in disaster response and recovery effortsHealth and social care providers are highly vulnerable to disaster‐related psychological distressThere is a lack of evidence‐based interventions to support the well‐being of health and social care providers in post‐disaster contextsThe Resilience and Coping for the Healthcare Community (RCHC) and expanded RCHC+ reduced anxiety, secondary traumatic stress and post‐traumatic stress symptoms among hurricane‐affected health and social care providersInterventions such as the RCHC may support provider's mental health during the disaster recovery and reduce and/or mitigate psychological distress1The consequences of environmental, technological and manmade disasters are both physical and psychological, and often have a lasting impact on survivors. Material damages to homes and communities, as well as injury and interpersonal loss, lead to multifaceted hardships  and burnout also disproportionately affect disaster‐affected health and social care providers , pre‐existing psychopathology, work‐related conditions , demographic factors (i.e. age and gender) and degree of social support , was originally developed and tested in Federally Qualified Health Centers (FQHCs) impacted by Hurricane Sandy in the states of New York and New Jersey, United States  and Texas (n = 14) that agreed to offer their employees the opportunity to participate in the intervention and study between June and August of 2018. Agencies included FQHCs, hospitals, disaster‐ = response agencies and community‐based health and behavioural health centres identified by research study coordinators from lists of service providers operating during the immediate post‐disaster period in partnership with AmeriCares, the international humanitarian disaster response organisation that funded and provided staff to conduct this intervention and study. Agency contacts also referred other agencies. Agencies were recruited from across each location .We recruited a total of 38 health and social service agencies in Puerto Rico  based on their facility's needs and availability. The rationale provided by agency personnel regarding their choice to research coordinators focused on logistical constraints. This pragmatic design was developed as a direct result of feedback from early agency partners who made it clear that random assignment to an intervention condition would not be feasible for their agencies.After an agency consented to participate, research coordinators worked with agency administrators to schedule the intervention session(s) in accordance with their assigned study condition (RCHC and RCHC+). To recruit participants within the organisation, information was provided through fliers and emails about RCHC, the study and time it would be delivered. Providers were eligible if they were as follows: (1) over 18 years of age; (2) able to speak and read English or Spanish; (3) experienced Hurricane Harvey or Maria and (4) were currently employed and working for a participating partner agency currently and at the time of the Hurricane. In collaboration with agency administrators, the research coordinators obtained a list of individuals who expressed interest and signed up to take part in the intervention.In Puerto Rico, all agencies in both RCHC and RCHC+ intervention groups chose to conduct the intervention and accompanying assessments in Spanish. Americares contracted the initial translation of the intervention curriculum which was then revised to fit the nuances of Puerto Rican Spanish by the programme coordinators, native Puerto Ricans. The full structure and all the psychoeducational content of the intervention remained the same. One activity that served to engage participants prior to later content delivery was modified to better fit the post‐Maria Puerto Rican context; however, neither the structure nor purpose of the activity was changed.Participants received either RCHC or RCHC+ and completed scales that assessed indicators of anxiety, PTSD, burnout and STS at baseline and two follow‐up time points: post‐intervention (12 weeks post‐baseline) and follow‐up (18 weeks post‐baseline). Approximately 1 week prior to the intervention, those who expressed interest were sent an electronic link to the informed consent form and baseline assessment to complete prior to receipt of programme services; agencies also had the option of using paper forms for participants. Participants were also given the option to consent and complete the baseline assessment at the time of the initial RCHC session. All participants were provided a $10 gift card incentive for completion of each survey. The study was approved by the Institutional Ethical Review Board at the University of Illinois Urbana, Champaign.n = 394; RCHC+ n = 368) and completed the baseline assessment. Retention across the study time points is shown in Figure n = 52 participants dropped out of the study , citing time and resource constraints. At post‐intervention (12 weeks), 694 of the 710 participants remained in the study and completed assessments. At follow‐up (18 weeks), 476 participants were retained. This manuscript presents the results of both the 12‐ and 18‐week measures and therefore, the data the 476 individuals retained for the entire study period were analysed and presented here.Participants included health and social care providers . A total of 762 participants (between 10 and 20 at each agency) consented to participate in the study , married (56.2%) and college educated, with nearly 60% having a bachelor's degree (30%) or a master's degree or higher (27.7%) Table . About h2.5Participants responded to a baseline questionnaire between 10 and 12 months after the hurricanes and follow‐up questionnaires at two additional time points, 12‐ and 18 weeks post‐intervention. At baseline, the questionnaire collected general demographic information  and the impact of the hurricane (e.g. home damage). Participants' well‐being was assessed at all three time points using three standardised measures: the Impact of Events Scale Revised (IES‐R) for PTSD symptoms  to 4 (extremely). Questions measured clusters of PTS, including avoidance (e.g. I stayed away from reminders about it), intrusion (e.g. Any reminder brought back feelings about it) and hyperarousal (e.g. I was jumpy and easily startled). IES‐R scores range from 0 to 88; a score of 0–23 is representative of low PTSD symptoms and 24–32 indicate that partial PTSD symptoms are present and of clinical concern. A score of 33–38 represents the clinical cut‐off for a probable diagnosis of PTSD, and a score of 39 or more indicates symptoms severe enough to suppress one's immune system functioning  was used to measure clinical anxiety symptoms in adults  scale, one of the most widely used scales to measure the professional quality of life among healthcare professionals Stamm, , measure2.6gYit represents the ordinal logit transformation of the outcome  for participant i at time t. RCHC represents the RCHC intervention, and RCHC+ represents the RCHC plus intervention. XRCHC_W12 and XRCHC+_W12 indicate which intervention the participant received (RCHC or RCHC+) at post‐assessment (W12). β1 and β2 represent the intervention effects. The participant‐level random intercept αi accounts for the correlated observations for the same participant. We estimated the following cumulative logit link mixed model for week 18:R (version 3.5.1) and the ordinal package  to estimate the multilevel ordinal models.We first calculated the frequency, stratified by location  and study condition , of symptom cut‐off scores at baseline for the mental health measures . We then estimated multilevel ordinal models to examine the association between participation in the RCHC or RCHC+ and change in PTSD, anxiety, burnout and STS symptoms across time. We analysed improvement in outcomes by calculating the odds of movement from a higher to a lower severity category at the 12‐ and 18‐week measurement timepoint, using ordinal mental health outcome variables (1 = change and 0 = no change) as they provide a better mechanism for analysing clinical significance of intervention benefits Hedeker, . Such or3At baseline, 19.1% of participants reported symptoms above the clinical cut‐off for a probable diagnosis or severe PTSD, slightly more 21.7%) in RCHC than in RCHC+ (19.2%) condition. Participants from Puerto Rico reported severe levels of PTSD at a higher rate (20%) than individuals from Texas (7%). Approximately 18.9% of all participants  reported moderate‐to‐severe anxiety. High rates of STS were also observed in both conditions prior to participation; 50.7% of participants in RCHC and 45.9% of participants in the RCHC+ condition reported symptoms in the high range for STS. Rates of burnout were lower, with 8.6% of participants in the RCHC and 6.6% of participants in RCHC+ reporting symptoms in the high range. Table 1.7% in RWe found that participants in both the RCHC and RCHC+ conditions had a higher likelihood of reporting a reduction in PTSD symptoms from baseline at both time points post‐intervention. At week 12, participants who received RCHC were 73% more likely to score in a lower severity category on PTSD symptoms from baseline (log‐odds −1.30). At week 18, participants remained 72% more likely to score in a lower severity category on PTSD symptoms from baseline (log‐odds −1.26). Similarly, participants in RCHC+ were significantly more likely to move from a higher to lower PTSD category from baseline at both time points , as seen in Table Levels of anxiety also decreased for participants in both intervention conditions, although the reduction was not significant for those in the RCHC group at the first post‐intervention assessment (12 weeks). For participants in the RCHC+ condition, the log‐odds of moving from a higher to lower anxiety category were − 0.80  at week 12. By week 18, the likelihood of a reduction in anxiety from baseline for both conditions was significant, 50% for participants in the RCHC+ group (log‐odds −0.69) and 47% for participants in the RCHC group (log‐odds −0.64). As shown in Table Participants in both RCHC and RCHC+ were also significantly more likely to experience a reduction in STS from baseline at week 12. The magnitude of change was smaller (log‐odds of −0.70) for the RCHC group than for the RCHC+ group (log‐odds of −0.86). At week 18, the likelihood of a reduction in STS from baseline was only significant for the RCHC+ group, although the magnitude of the likelihood of reduction had decreased (log odds of −0.77). As shown in Table 4The present study examined the effects of the RCHC and expanded RCHC+ on health and social care providers' mental health in two hurricane‐affected regions. We found high rates of psychological distress among health and social care providers in both Texas and Puerto Rico after experiencing major Hurricanes in 2018, and evidence that participation in RCHC and expanded RCHC+ may positively impact providers' mental health. Prior to participation in RCHC (approximately 12 months after the hurricanes), providers reported high levels of PTSD, anxiety and STS symptoms. After participation, we found that providers reported significant reductions in mental health symptoms across outcomes in both intervention conditions. The likelihood of a reduction in symptoms of anxiety and STS from baseline was sustained at both time points for participants in the RCHC+ condition.At baseline (approximately 12 months after the hurricanes), providers in our study reported higher PTSD symptoms than reported in the general population ; a rate consistent with studies of STS among providers responding to environmental , and of anxiety only at the 18‐week follow‐up for those in the RCHC cohort. Taken together, however, we suspect that the lack of a significant difference in the changes among individuals who participated in the RCHC may be due to the larger standard errors resulting from a smaller sample size rather than a true non‐effect at the population level. Although these findings appear to suggest the more intensive RCHC+ intervention may yield greater benefits for providers in post‐disaster settings; further examination with larger sample sizes is needed to substantiate this distinction.Participants in both intervention conditions were slightly more likely to report a reduction in burnout from baseline, however, not to a significant degree. There are several potential reasons for this finding. First, high levels of burnout were not detected prior to participation in either intervention, the majority of participants (55.2%) reported low levels. Therefore, it was unlikely we would observe a significant reduction in burnout given the limited opportunity for improvement Hedeker, . AdditioOur study yielded promising findings; however, several limitations should be noted. First, our real‐world post‐disaster services context did not allow for a controlled trial due to the continuously changing context of the disaster response organisations, and the threat of additional weather events in the year following Harvey and Maria. Discussions with partnering agency stakeholders early in the design process identified these challenges, which we addressed by using a pragmatic design. Pragmatic designs may produce outcomes more readily generalisable to real‐life practice settings than highly controlled trials  after participation in the RCHC and RCHC+ intervention. These findings have occupational health implications for health and social care providers who work in disaster response and recovery efforts in the United States and internationally. Given the high levels of psychological distress among providers during response and recovery, employers and disaster recovery organisations could better anticipate the need for mental health support and incorporate strategies to mitigate symptoms. Advanced planning for employee care and evaluating policies to minimise shift burden during response and recovery could reduce distress and improve the resiliency of the workforce.Additionally, we found that both the RCHC and RCHC+ interventions may reduce psychological distress, suggesting they could be an important part of advance planning to support provider's mental health during a disaster. Incorporating the intervention into organisational scheduling during the response and recovery period could support providers in mitigating distress. More research is needed, however, to clarify the effectiveness of RCHC. Studies that include control groups, as well as the examination of the RCHC with other populations, such as individuals who are not first responders and members of other occupations, such as teachers, clergy and law enforcement officers, across a wider variety of disaster contexts both in the United States and internationally could add to the assessment of the intervention's efficacy. Additionally, further examination on how RCHC affects psychological distress in contexts of consistent and sustained disaster could provide insight into the responsiveness of RCHC to more enduring symptoms.Conception and design of work ; data collection ; data analysis and interpretation  and manuscript preparation .The authors have no potential conflicts of interest to disclose.


A 53‐year‐old man, with no significant past medical history or family history of sudden cardiac death (SCD), was admitted to the Emergency Department for transient of loss consciousness (TLOC) and facial trauma. The TLOC occurred at rest, in an upright position, without prodromes and/or specific triggers. The patient was not taking any drugs or substances that could have explained the TLOC. At admission, the body temperature was 37.8°C. The blood tests and the chest radiography suggested the diagnosis of bacterial lobar pneumonia. Transthoracic echocardiography (TTE) showed no cardiac abnormalities. The electrocardiogram (ECG) showed a coved type downward ST‐segment elevation in V1 and V2 followed by a negative T wave, compatible with the type 1 Brugada pattern , such as the patients' management (conservative or invasive). Head‐up tilt test (HUTT) performed according to the Italian Protocol showed the induction of vasodepressive syncope without prodromes, characterized by a sudden fall in blood pressure with increased heart rate Figure . An endoThe evaluation of syncope in BrS patients, especially in those with type 1‐induced ECG pattern, represents a challenging issue since a differential diagnosis from neurally mediated and arrhythmic forms is mandatory to optimize clinical management. The clinical presentation of syncope may be not sufficient for distinguishing neurally mediated from arrhythmic syncope. Indeed, specific triggers and typical prodromes may be present in both forms of syncope among patients with channelopathies and may often precede the nonarrhythmic syncope.Although in BrS patients, there is a high incidence of neurally mediated syncope, the etiology of syncope is difficult to determine in up to 30% of BrS patients.The use of an implantable loop recorder (ILR) should be considered in patients with Brugada pattern and unexplained syncopeImplantable cardioverter‐defibrillator (ICD) implantation should be limited for patients with type 1‐induced Brugada pattern with documented arrhythmic syncopeSyncope without prodromes represents a challenging clinical issue in patients with channelopathies. A careful comprehensive evaluation aiming to exclude the correlation between arrhythmic events and clinical symptoms should be considered in the patients' centered care of subjects with type 1‐induced BrS pattern.This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.Authors declare no conflict of interests for this article.


Acquired idiopathic generalised anhidrosis (AIGA) is a rare disorder that is characterised by sudden onset generalised absence of sweating without any dermatological, neurological or sweat gland abnormalities. AIGA predominately affects young males, mostly involving patients of Asian descent. There have been approximately 100 reported cases worldwide, most of which were reported in Japan. In Singapore, it is rarely seen with one case series on 15 cases of AIGA reported in a 2014 study. Here, we present a case of AIGA who responded well to conservative management with sweating activity. Sudden onset anhidrosis in an otherwise healthy 59‐year‐old Chinese male who presented to the dermatology department with a 3‐month history of a sudden lack of sweat production after picking up long distance cycling for 2 months He had previously never engaged in such strenuous exercise. The lack of sweating was associated with urticaria and feeling faint during exercise. The patient was otherwise fit and well with a unremarkable medical history of well‐controlled high cholesterol and gout for which he was taking simvastatin and allopurinol. He denied any previous skin inflammatory disease or any autoimmune disease. Laboratory investigations ordered revealed a normal IgE level.A starch‐iodine sweat test was performed to confirm the extent of anhidrosis Figure . After 4After 4 months of follow‐up, our patient's anhidrosis spontaneously improved with conservative management. New areas of sweating were present over his arms and chest.2Anhidrosis can be spilt into either congenital or acquired. Congenital anhidrosis involves congenital alterations in the eccrine glands as seen in congenital anhidrotic diseases such as Hypohidriotic Ectodermal Dysplasia (HED), Congenital insensitivity to pain with anhidrosis (CIPA) or Fabry disease. On the other hand, acquired anhidrosis can be spilt into 2 subgroups: idiopathic anhidrosis or secondary anhidrosis. Secondary anhidrosis can be attributed to organic causes in the form of central or neuropathic disease as well as due to certain medications.In this case, due to absence of organic causes, this is a form of acquired idiopathic generalised anhidrosis (AIGA).AIGA can be associated with 3 subtypes: sudomotor neuropathy, idiopathic pure sudomotor failure (IPSF) and sweat gland failure (SGF).Most cases of AIGA are categorised under idiopathic pure sudomotor failure (IPSF), whereby skin biopsies are either normal or have mild peri‐eccrine lymphocytic infiltrate. It is also characterised by diminished sweating with sudomotor stimuli characterised by hyperthermia, dry skin, itch or tingling of the skin surface.The pathophysiology of IPSF remains relatively unknown. However, autoimmune mechanisms targeting the CHRM3 (Cholinergic Receptor Muscarinic 3) receptors have been noted as a possible cause in recent literature. Their response to the binding of acetylcholine is inhibited, resulting in a lack of sweat response.In IPSF, only the eccrine sweat glands with cholinergic innervation are affected. Apocrine sweat glands of the axilla are under adrenergic control while eccrine sweat glands of the palms and soles are under both adrenergic and cholinergic control. Hence, this could be the reason for continued sweating over the palms and axilla region.IPSF also commonly presents with cholinergic urticaria. Cholinergic Urticaria usually occurs during perspiration and involves acetylcholine. It was proposed that cholinergic urticaria can be categorised into 2 subtypes: acetylcholine‐indirectly induced, sweat allergic type and acetylcholine‐directly induced, depressed sweating type.In contrast, in the acetylcholine‐directly induced type which is also recognized as Cholinergic Urticaria with anhidrosis/hypohidrosis, eccrine sweat glands lack the expression of CHRM3 receptors thus the expression of CHRM3 is absent in anhidrotic areas and slightly present in hypohydrotic areas. The possible pathophysiology behind this is that acetylcholine released cannot be trapped by the absent CHRM3 receptors, resulting in an increase in the levels of acetylcholine into adjacent mast cells. This subsequently results in mast cell degranulation hence the formation of wheals.There has been a case report on 2 patients with this subtype of anhidrosis experiencing sharp, pinprick pain over their body sparing their palms and soles, exacerbated by heat and exercise.In order to distinguish it from the 2 subtypes, skin biopsy should be done first, followed by other tests such as electromicroscopy or autonomic fibre marker vasoactive intestinal peptide.In this case, it is likely that our patient had the IPSF subtype due to the presence of normal eccrine sweat glands with mild peri‐eccrine infiltrates Figure , sudden Regarding the possible triggers, sudden onset of anhidrosis has been similarly reported in young males undergoing mandatory national service training, and also in horses that have been trained strenuously under hot and humid conditions (equine anhidrosis).Sweating is important in regulating human body temperature by dissipating thermal energy from skin surface when water in sweat evaporates.There is also evidence of association of AIGA with autoimmune diseases in the form of complications. Thus, it could be postulated that AIGA may be mediated via immunological and inflammatory mechanisms.In this case, spontaneous resolution occurred with conservative management.It is equally important for the treatment of this condition to be anchored in good patient education.None to declare.Clara Michelle Tan Hwei Sian Tan: Writing – original draft ; Writing – review & editing . Rayson Rui Sheng Lee: Investigation ; Methodology ; Supervision ; Writing – review & editing . Janet Pei Ling Dua: Data curation ; Formal analysis ; Investigation ; Methodology ; Supervision ; Writing – review & editing Not applicable.


This paper theorises and empirically assesses how education and active labour market policy (ALMP) relate to each other in shaping individuals' employment chances in Europe. It provides a theoretical base for assessing policy complementarities building on sociological skill‐formation literature, varieties of capitalism and social investment literature. Two hypotheses of complementarity are advanced: reinforcement whereby higher investment in general skills via education boosts ALMP effectiveness; and substitution‐compensation whereby investments in either policy suffice, rendering individual employment chances less dependent on ALMPs at higher (prior) educational investment levels. The advanced theoretical propositions are empirically tested by looking at how individual employment chances are affected by national ALMP efforts conditional on workforce education, distinguishing between individual‐ and national‐level educational attainment. Analyses draw on micro‐level EU‐SILC longitudinal data 2003–2015 from 29 European countries and 285 country‐years applying mixed‐effects dynamic panel regression models. Results highlight the complementarity of education in the functioning of ALMPs and show that the education‐ALMP interplay follows different dynamics when individual or national education are considered, with substitution‐compensation for the former and reinforcement for the latter. Higher individual educational attainment is associated with lower marginal returns from national ALMP efforts, with higher ALMP effectiveness among the lower‐educated. By contrast, higher national educational attainment is associated with increased ALMP effectiveness, with ALMPs tending to be far less effective at low levels of highly educated workforce. Different interaction patterns are observed for youth, indicating increased difficulty in activating this risk group. The contemporary welfare state approach to dealing with economic and social challenges is geared towards human capital formation, preservation and activation  educational investments increase ALMP effectiveness. The theoretical framework distinguishes between the moderating role of individual and national level educational attainment in the functioning of ALMPs.This article follows up on the call to study policy complementarities, focusing on the education‐ALMP interplay. The contribution of this article is both theoretical and empirical. Theoretically, it provides an analytical base for assessing the education‐ALMP interplay, building on the skill formation literature at a micro level  of one increases the returns from (or efficiency of) the other’  longitudinal surveys 2003–2015 from 29 European countries, retrieved from the statistical office of the European Union (Eurostat).by Borst , and com4.2The dependent variable is individual self‐defined employment status, operationalised as a binary measure equal to 1 if an individual at the time of interview was employed, and 0 if not employed. The category ‘employed’ comprises full‐time and part‐time employees and self‐employed; ‘not employed’ comprises the unemployed and inactive persons, including those fulfilling domestic tasks and care. Analyses exclude pupils, students, the permanently disabled or unfit to work, those in retirement and those in compulsory community or military service. In this final sample, 80% of observations were categorised as ‘employed’ and 20% as ‘not employed’. Among those not employed, 20% switched status to employed during the observed 2‐ to 4‐year period.The first independent variable of interest is active labour market policy (ALMP) effort. It is operationalised as public spending on ALMPs as a percentage of GDP, divided by the share of unemployed. Data were retrieved from Eurostat's Labour Market Policy expenditure summary tables ; average education including lower or higher secondary or post‐secondary but not higher education (46.6%); and higher education including college and university (28.5%). Within the low educational attainment category, previous literature suggests variation in ALMP effectiveness, with the least disadvantaged among this risk group potentially benefitting more from ALMPs . For the base models, it is coded into three categories: highly educated workforce, which in the analysed country‐year sample ranges from 12.3% in Italy in 2005 to 45.9% in Luxembourg in 2014.National‐level education is measured as a share of persons aged from 25 to 64 years with tertiary education (levels 5–8 according to the ISCED 2011 classification) retrieved from Eurostat  . The seFigure Adult learning and training programme participation constitutes an important source of continuous knowledge acquisition that can increase individuals' competitiveness and employability. Contrary to ALMPs, adult learning and training are also available to those with stable employment and tends to be taken up by better educated individuals  and 5 (very bad); marital status equal to 1 if married and 0 if otherwise; household size; and number of very small children under age 2. At the macro‐level, selected controls account for national macro‐economic conditions and the overall welfare state generosity that are known to influence individuals' employment chances. These are: purchasing power adjusted GDP per capita at current market prices  were excluded from the total ALMP spending measure; the 5In this section, we empirically test the education‐ALMP interplay in affecting employment chances in the European context. Table Cross‐level interaction: individual educational attainment and national ALMP effortsp‐value < 0.01). This implies diminishing marginal returns to higher ALMP efforts for the highly educated, and increased ALMP effectiveness for the lower‐educated.Corroborating what is generally found in the literature, estimates in Table X‐axis represents contexts with average ALMP spending efforts. The lighter (dashed) and darker (solid) lines represent sampled individuals with higher and lower educational attainment, respectively.Further analyses by age (M4–M6) reveal that the estimated averages for the total workforce do not apply equally to all. To have a clearer understanding of the interaction effects, estimates are expressed in predicted employment probabilities and plotted across the ALMP spending distribution in Figure A clear substitution‐compensation pattern in the education‐ALMP interplay is observed for people of prime working age and older workforce .Table Figure The estimated reinforcement effect remains close to identical when controlling for individual educational attainment, and when excluding the training category from the total ALMP measure (Tables Estimates presented here do not imply causality since other unobserved welfare state characteristics beyond education and ALMPs may drive the observed patterns. All models control for the macroeconomic context, welfare state generosity and adult learning participation, but other factors may not be accounted for here.6This paper theorised and empirically assessed education‐ALMP complementarities affecting employment chances among a large sample of working‐age individuals residing in 29 European countries. Two alternative hypotheses were proposed: reinforcement predicting higher ALMP effectiveness when workforce education is high; and substitution‐compensation predicting diminishing ALMP returns at higher education levels and increased ALMP effectiveness at lower education levels. Education‐ALMP interplay was tested considering individual and national education separately as this distinction has not only theoretical but also policy‐relevant implications.When considering individual‐level education, results are in line with the substitution–compensation hypothesis. A highly educated workforce tends to be less dependent on ALMP efforts: their employment chances are relatively higher and vary less across the ALMP distribution. For a lower‐educated workforce, employment probability tends to increase at higher levels of ALMP effort, implying that activation policies somewhat compensate for the lack of prior educational investment. The identified substitution‐compensation effect is reassuring since it means that ALMPs benefit lower‐educated individuals more, contrary to the Matthew Effects assumption. Nevertheless, even with high ALMP efforts, employment probability among lower educated individuals is lower than among a highly educated workforce, indicating that the employment gap between low and highly educated does not close even at high ALMP levels. For youth, education and ALMPs are mutually reinforcing, with higher ALMP effectiveness for highly educated youth. This indicates that lower educated youth is at increased risk of labour market exclusion and benefits less from ALMPs, implying that more targeted interventions could be considered.When considering national workforce education and how it relates to ALMP efforts, results reveal a clear pattern of reinforcement. Investments in ALMPs, combined with a large share of highly educated workforce, are associated with a substantially higher employment probability compared to the same ALMP efforts but a lower share of highly educated workforce. This applies to all age groups, with somewhat weaker reinforcement among youth. This might be because in settings with high workforce education, it is harder to activate youth, also at high ALMP spending levels.Regarding policy implications, this paper shows that national workforce educational attainment has bearings on ALMP effectiveness, and therefore the choice of optimal labour market policy strategies. Relative abundance of a highly educated workforce constitutes a reinforcing effect whereby employment transitions can be boosted by more ALMP efforts. The identified reinforcement dynamic implies that high employment levels can be reached when coupling investments in formal education with ALMP. Low educational investments are associated with a lower employment probability and less effective ALMPs which are unable to compensate low general education levels.The findings of substitution for individual‐level education and reinforcement for macro‐level educational attainment may seem contradictory but are theoretically reconcilable. The substitution effect when individual education is considered indicates that ALMPs are more beneficial and/or more likely to reach the lower educated. As outlined in the theoretical framework, this may be driven by increased employability and self‐sufficiency among highly educated jobseekers and/or a positive ALMP access bias among the lower educated jobseekers, or other mechanisms not described here. The reinforcement effect when considering macro‐level education, in turn, underlines that ALMP effectiveness depends on the overall workforce education, with a more highly educated workforce at state level boosting ALMP effectiveness in promoting employment. Theoretically, it was argued that this may stem from differential work‐level production strategies and subsequent hiring behaviour, but it could also result from better‐quality ALMP service provision or other welfare state characteristics not accounted for here. An important future research avenue is to test the theorised micro‐mechanisms behind the identified interaction effects to uncover the causes of these associations. It is also important to capture longer time periods so that within‐country variation could be exploited better.DATA S1. Supporting information.Click here for additional data file.


Moniezia spp. This study employed a combination of molecular and statistical methods that improved the estimates of prevalence and shedding intensity and allowed us to compare the performance of four diagnostic tests while assessing the effect of covariates. Such improvements are critical to enhancing inference in non‐invasive wildlife copro‐parasitological studies.Copro‐parasitological surveys in wildlife face challenges due to the secretive nature of many species and the unknown performance of the diagnostic tests employed. To overcome these issues, we used a combination of hierarchical models (site‐occupancy and N‐mixture models) applied to copro‐parasitological data obtained from fecal samples assigned to the host species by molecular methods in the Iberian ibex in north‐western Iberian Peninsula. The aims were to compare the performance of four diagnostic tests  and to use this methodological approach  to better estimate positivity proportion and shedding intensity in a wild ibex population. Pooled fecal samples were collected, and those confirmed by molecular analyses to be the host species in question were included in the study. Hierarchical models confirmed different performances of each diagnostic test, with Mini‐FLOTAC showing higher sensitivity for eimeriid coccidia, Willis flotation (for proportion positive) and McMaster (for shedding intensity) in gastrointestinal Strongylida, and equal performance of MiniFlotac/Willis flotation (for proportion positive) and MiniFlotac/McMaster (for shedding intensity) in  Parasitological survey of wild caprines in a transfrontier protected area in the Iberian Peninsula. Addressed through molecular techniques and applied hierarchical models to correct prevalence and shedding intensity by the imperfect test sensitivity. The aims were to compare the performance of four diagnostic tests while assessing the effect of covariates. Such methodological improvements are critical to enhancing inference in non‐invasive wildlife copro‐parasitological studies. DNA extraction was performed using the EXNA® Tissue DNA KIT  and the polymerase chain reaction‐restriction fragment length polymorphism (PCR‐RFLP) for species identification  from the replicates of each diagnostic test performed on each sample, this being the sensitivity of the qualitative tests and the probability of detection of one egg or oocyst/gram of feces (quantitative methods). The state models estimate the positivity proportion (site‐occupancy models – ψ) and counts (N‐mixture model—N) corrected for the imperfect detection probability. The true positivity proportion (ψ) was estimated from presence/absence data obtained from the three replicates per sample of each of the four diagnostic tests, using the site‐occupancy model of MacKenzie et al. . SheddinK = 1500  as observation covariate and ‘nucleus’  as site covariates. For each parasite group, the full model was fitted for site‐occupancy and N‐mixture analysis, including all variables in the detection model and the site covariates in the state model using the replicates as response variables. The N‐mixture model was fitted using a negative binomial distribution with Using the most supported model for each of the parasite groups we then calculated the detection probability of each of the diagnostic tests employed Table . Using t3Tricostrongylus spp. and Nematodirus spp.), and Moniezia spp. In all the most supported models, except for the shedding intensity of Moniezia spp., the detection probability varied with the diagnostic method  and apparent shedding intensity (OPG and EPG) by the imperfect detection probability of each diagnostic test  (Table Moniezia spp. (0.01)  Table . No singIt should be noted that the detection probability estimated refers to the specific protocols used in this study. The McMaster technique employed a lower volume of feces than the Mini‐FLOTAC and increasing it could potentially improve the sensitivity of this method. Due to the logistical constraints of fieldwork in remote areas, samples had to be refrigerated for 4 weeks, potentially decreasing the detection probability  corrects the biases arising from the incorrect specific assignment of samples. Hierarchical models are inherently suited to estimating the sensitivity of the parasitological methods employed and correcting the apparent prevalence and shedding intensity for imperfect sensitivity. Such methodological improvements are critical to enhancing inference in non‐invasive wildlife copro‐parasitological studies.Catarina Fontoura‐Goncalves: Data curation ; formal analysis ; investigation ; writing – original draft ; writing – review and editing . Érica Portocarrero: Data curation ; formal analysis ; investigation ; writing – original draft ; writing – review and editing . Ana Oliveira: Data curation ; formal analysis ; investigation ; writing – original draft ; writing – review and editing . João Lozano: Formal analysis ; methodology ; validation ; writing – review and editing . Laura Rinaldi: Funding acquisition ; resources ; writing – review and editing . Giuseppe Cringoli: Funding acquisition ; resources ; writing – review and editing . Luís Madeira de Carvalho: Conceptualization ; data curation ; funding acquisition ; methodology ; project administration ; resources ; supervision ; validation ; writing – review and editing . Nuno Santos: Conceptualization ; data curation ; formal analysis ; funding acquisition ; investigation ; methodology ; project administration ; resources ; supervision ; validation ; visualization ; writing – original draft ; writing – review and editing .On behalf of all authors, the corresponding author states that there is no conflict of interest.


Family quality of life (FQoL) outcomes collected during the first year of COVID‐19 has been combined with 2018 data to estimate the outbreak's impact on parental outcomes on a sample of 230 families with syndromic autistic children and those with intellectual disabilities (IDs). Despite challenges imposed by the COVID‐19 outbreak, our study found that FQoL outcomes reported by participating parents during the first year of COVID‐19 appears to be similar to ratings from a prepandemic study of families with the same conditions. Parents of children in our sample generally displayed a stable functioning trajectory as measured by the validated FQoL instrument. Across syndromic autistic groups considered, families reported that their relationships with their children were positive. Our findings provide evidence of families' resilience which might explain the presence of positive parent–child interactions during COVID‐19. Exploring mechanisms which would explain how families with autistic and ID children confront, manage disruptive experiences, and buffer COVID‐19 induced stress is a fruitful direction for future research. Despite challenges imposed by the COVID‐19 outbreak, our study found that the quality of life reported by participating families during the first year of COVID‐19 appears to be similar to ratings from a prepandemic study of families with the same conditions. The COVID‐19 pandemic and related lockdowns were found to be positively associated with parent–child bonding, relational satisfaction, and increased emotional connection between parents and their children. Our findings provide evidence of families' resilience which might explain the presence of positive parental–child interactions during COVID‐19. The COVID‐19 pandemic has had an undisputed impact on children and families. Recent research has found an increased risk of negative mental health, neurodevelopmental, and health‐related quality of life outcomes among children  relationships has been found to be a significant predictor of outcomes for children especially during periods of stress and uncertainty . These disorders strongly predispose a child to a diagnosis of autism or ID , Rett syndrome (RTT), and SYNGAP1‐ID, while they share common traits, have distinctive clinical characteristics. A previous study identified differences in FQoL average scores across these disorders related to family interaction, and parenting domains  to assess the impact of COVID‐19 on FQoL outcomes using identical and validated measures collected between 2018 and during the first year of the pandemic on a sample of families recruited via identical methods; (c) to compare FQoL outcomes from earlier and later phases of the first year of the outbreak. Finally, (d) to evaluate the PC relationships and overall experiences of parenthood during the first year of COVID‐19, and to estimate the association between pandemic induced factors with those relationships and experiences.This study was designed to advance the following research aims: (a) to document parental COVID‐19 environments of children diagnosed with single‐gene disorders which are strong risk factors for developing an ASD, syndromic autism or ID: PMD, RTT, and SYNGAP1‐ID completed self‐report questionnaires in order to ascertain COVID‐19 induced lifestyle changes, FQoL and PC relationships. Study participants were distributed as follows: 138 (60%) parents with children diagnosed with PMD, 50 (22%) parents of children diagnosed with SYNGAP1‐ID children and 42 (18%) parents of children diagnosed with RTT. This study was approved by Baylor College of Medicine's Institutional Review Board. A recruitment email provided access to an online Qualtrics survey distributed by: PMD Foundation, RettSyndrome.org and SYNGAP1‐ID Education and Research Foundation. In order to complete the web‐based questionnaire the participants had to read and understand English and have Internet access. Before completing the questionnaire, the respondents gave their informed consent.This study used data collected at two points in time: prior to COVID‐19, specifically during 2018 as previously described  were found regarding the following variables: estimated total annual household income and the type of health insurance of the caregiver. In particular, the evidence shows that parents of SYNGAP1‐ID children were more affluent  followed by PMD with 49% and RTT with 42%. In addition, almost 50% had private health insurance followed by PMD with 35% and RTT with 31%. Parents of SYNGAP1‐ID children had the highest proportion of graduate or professional degrees with 49% followed by PMD 37% and RTT 32%. However, the overall evidence suggests that the majority of socioeconomic covariates were largely balanced across each of the three diagnoses.Table SYNGAP1‐ID, and RTT when parents were asked if they were able to maintain a predictable routine during COVID‐19. Overall, 15% of caregivers reported an inability to maintain a predictable routine during the COVID‐19 pandemic. This proportion was the highest among parents of PMD children (23%), followed by RTT parents (7%), and SYNGAP1‐ID (5%).Table Results also show significant differences across diagnoses when we measured experiences of family stress concerning potential exposure to COVID‐19 at work or while commuting to and from work, as well as, when measuring a caretaker's ability to provide basic needs such as food, housing, and medical care. Thus, more than 80% of parents reported being somewhat stressed or very stressed due to potential exposure to COVID‐19 with the greatest proportion of highly stressed parents recorded within RTT. Over half of caregivers reported that some money was left over at the end of the month during the pandemic, however, the overall proportion of parents who did not have enough to make ends meet was close to 9%. This was the highest within RTT (15%). Notably, 47% of caregivers reported having help with childcare during “shelter in place” orders, and over 55% of parents reported that their help came from someone outside of their home.Reported evidence in Table SYNGAP1‐ID patients had a minor increase related to family interaction score and emotional score. However, no differences were detected within families of PMD and RTT patients between data gathered before and during COVID‐19. Additional details can be found in Appendix Table To ascertain the impact of early versus late COVID‐19 on average FQoL scores, and to control for heterogeneity across clinical profiles, we randomly matched observations before and after September 25th according to clinical diagnosis. From the start of data collection before and on September 25th (55.7%) respondents completed the survey. Given the sample sizes across diagnoses shown in Table SYNGAP1‐ID, and RTT. We found statistically significant differences across diagnoses when we asked if children were turning to their caretakers with personal problems, as well as, how often a child depended on the caretaker's help, advice, or sympathy. Results were then paired with the caretaker's role in cheering up the child during the pandemic. Furthermore, statistically significant differences were found when we asked caretakers if they were quarreling or disagreeing with their child as a result of the COVID‐19 pandemic.Table SYNGAP1‐ID. These trends continued with 68.7% of parents and caretakers responding that they never/hardly at all argue with their children, 75.5% never/hardly at all say mean or harsh things to their children, 74% answered never/hardly at all criticize their children. Finally, 65.3% of respondents answered that they never/hardly at all put their child down.When considering the presence of conflict in a child with syndromic autism, our results indicated that the root of that conflict is often not the PC relationship with 44.4% of respondents reporting that they never/hardly at all disagree or quarrel with one another. Parents of PMD children reported the lowest levels of disagreement or quarreling with 53.8% reporting never/hardly at all as compared with 53.6% with RTT and 20.9% from SYNGAP1‐ID PC relationships, and 78.6% among RTT PC relationships. Results show that support seeking was also high among SYNGAP1‐ID children with 34.9% reporting that they always seek support and 46.5% seeking support often. These results also remained high among RTT children with 29.6% always and 37% often seeking support. On the other hand, data showed that PMD children had lower support seeking behaviors with 33.8% never/hardly and 16.3% sometimes seeking support. Across all diagnosis 59.2% of respondents reported spending fun time with their child always or often, and 50% responding that they always or often go places and do things together with their children. The evidence indicated that 41.1% of children still depended on their parents for help, advice, or sympathy during the pandemic, and 30% of children always relied on their parent paired with 33.3% who relied on them often during the pandemic to cheer them up when they were feeling down. The parents of children diagnosed with RTT reported feeling a lot more connected during the outbreak than before (32.1%) followed by SYNGAP1‐ID with 28.6% and PMD with 25%.When asked how happy parents were with their relationship with their child an overwhelming majority reported being happy always (30.3%) or often/very often (38.8%) in their interactions. Across each diagnosis we consistency saw in this area a combination of being happy always or often/very often in the relationship with 66.7% with PMD PC relationships, 67.4% among Table Results from our analyses that examined the association between COVID‐19 parental environments and average P‐C scores were similar in magnitude and direction to average FQoL scores reported in the previous paragraph. In particular, a caregiver's ability to maintain a predictable routine or schedule during COVID‐19 was associated with 4.31  points in average P‐C scores. Furthermore, an indicator for a child's somewhat successful or very successful completion of home school assignments was associated with 6.20  in P‐C average scores. However, in equations designed to predict average FQoL and average P‐C scores the indicator which denoted that some money was left over at the end of the month during the pandemic was not significant. Interestingly, changes to a caregivers' access to healthcare was not found to be associated with average P‐C scores.SYNGAP1‐ID, and RTT. The availability of FQoL data primarily collected during 2018 and the first year of the pandemic allowed us to estimate the impact of COVID‐19 on a family's quality of life outcomes and compare FQoL outcomes during earlier and later phases of the outbreak. Furthermore, we ascertained the PC relationships and overall parenthood experiences during COVID‐19, and estimated the association between pandemic induced factors and parental experiences among syndromic autistic families.In this study, we documented parental environments during the first year of the COVID‐19 pandemic of autistic and ID children diagnosed with PMD, Consistent with previous research we found that the COVID‐19 pandemic significantly changed families' routines (Cluver et al., SYNGAP1‐ID families. Furthermore, no differences in average FQoL scores for parents of autistic children were detected between earlier and later phase of the first year of the pandemic.The evidence in this study consistently demonstrated that within the combined sample there were no statistically significant differences in average FQoL scores between 2018 and during the first year of COVID‐19. Furthermore, no differences were detected in FQoL resilience related constructs such as family interaction Bonanno, , or pareDespite significant pandemic‐induced challenges for parents, our results indicated a strong bond between parents and their children during this time as an overwhelming majority of parents reported being always or often/very often happy in their interactions with their children. The overall high ratings of relational satisfaction are supported in other questions within our dataset that focus on levels of social support experienced between parents and their children during the pandemic across each diagnosis. The presence of a supportive environment and positive parenting is shown by the high rates of support seeking behaviors from children to their parents during the first year of the pandemic. The supportive environment of the PC relationship during COVID‐19 is also shown in responses centered on having fun during their time together as almost 2/3 of respondents reported spending fun time with their child always or often, and 1/2 of respondents stating that they always or often go places and do things together with their children. Furthermore, results have shown that emotional support remained a top support seeking behavior from autistic children during the pandemic.The low presence of conflict reported in our data, coupled with the high‐levels of support seeking and quality interactions between parents and their children during the pandemic are present within our findings and overall indicate resilience and positive parenting. The data also showed that parents across diagnosis reported some increase in the feelings of connection with their children during the outbreak. Overall, the PC relationships showed incredible strength and our parent participants showed enormous resilience in caretaking during a stressful period.Results also demonstrated the presence of resilience in the context of stressful COVID‐19 environments across PMD, SYNGAP1‐ID and RTT families. First, the evidence consistently demonstrated that COVID‐19 had adversely impacted parental environments. Surprisingly, overall only 15% of caregivers reported an inability to maintain a predictable routine during the COVID‐19 pandemic which was well below the rates reported in the literature during similar periods (Adams et al., Overall evidence in this study suggests that resilience is the likely mechanism that explains positive PC outcomes during COVID‐19. Moreover, the presence of families' resilience is shown because a high proportion of parents reported having support with children during the pandemic; however, the literature consistently found that social support is predictive and a marker of resilience (Kapp & Brown, Evidence of resilience in our findings is also demonstrated in Table SYNGAP1‐ID, its results are likely generalizable to other neurogenetic disorders with high comorbidity of autism such as Fragile X syndrome. Although FQoL was not specifically measured before and during the COVID‐19 pandemic, one report did suggest that mothers of children with Fragile X syndrome maintained self‐efficacy in caring for their children's behavioral problems during a COVID‐19 related lockdown (Di Giorgio et al., While this study focused on three neurogenetic disorders, PMD, RTT, and Overall, our results provided evidence which might reconcile the contrasting findings around the impact of the pandemic on parents and their relationship with their autistic children (Ameis et al., The major strength of this study is the longitudinal design which used identical and validated FQoL measures primarily collected during 2018 and the first year of the COVID‐19 pandemic on families with syndromic autistic children. Another major strength of the study is that it collected rich and novel data during COVID‐19 which ascertained exposure‐outcome relationship consistently over and across genetic disorders that strongly predispose to syndromic ASD and ID. This study collected novel data on PC activities and interactions during the COVID‐19 pandemic across different syndromic autism disorders which is also a strength.SYNGAP1‐ID registry reported during the prepandemic data collection (Bolbocean et al., The study's main limitation is that participating families in the prepandemic study are not necessarily identical to families with the same conditions that participated in the COVID‐19 study, even though participants in both studies were recruited using identical methods and sample frames. Thus, reported estimates do not necessarily represent causal relationships. Another limitation is that socioeconomic variables were not collected for the prepandemic study and that the participating parents in 2018 and during the pandemic surveys are not necessarily the same. Thus, observed differences in FQoL scores before and during the first year of the pandemic were not adjusted for the socioeconomic factors. However, the studies before and during the pandemic recruited participants using identical methods and patients' registries within a relatively short time‐frame. This suggests that there might be a significant overlap of participating families in both studies. However, the evidence in Table The participating families were registered with charities which suggest that they may be well connected and possibly followed by an informed team of health care providers. Thus, it is possible that the families who did participate in the study were more stressed and they would rate their FQoL differently which might limit the generalizability of our findings. The generalizability of our results might also be limited because the participating families were relatively homogeneous with respect to the socioeconomic gradient of health. In addition, P‐C ad‐hoc index was not a validated measure of parental–child interactions. Finally, due to the nature of data collection process we were not able to confirm the diagnosis in participant families.Despite challenges imposed by the COVID‐19 outbreak, our study found that the quality of life reported by participating families during the first year of COVID‐19 appears to be similar to ratings from a prepandemic study with families with the same conditions, some of whom may have been in the COVID‐19 study. Overall, parents of children in our sample generally displayed a stable functioning trajectory as measured by FQoL instrument. Quality of life outcomes for families who completed surveys before and after the commencement of school activities during September 2020 did not appear to differ. The COVID‐19 pandemic was found to be positively associated with PC bonding, relational satisfaction, and increased emotional connection between parents and their children. Our findings provide evidence of family resilience which might explain positive PC interactions during COVID‐19. Exploring mechanisms which explain how families with autistic and ID children confronted, managed disruptive experiences, and buffered COVID‐19 induced stress is a fruitful direction for future research.All study procedures were prospectively reviewed and approved by the institutional review board of the Baylor College of Medicine Houston, TX US.APPENDIX S1: Supporting InformationClick here for additional data file.


Estimated incubation period distributions of mpox using cases from two international European festivals and outbreaks in a club in Berlin, May to June 2022’ by McFarland et al., published on 6 July 2023, the references from number [16] onwards were misnumbered. The reference numbering was corrected on 10 July 2023. We apologise for any inconvenience this may have caused.In the article entitled ‘


Pemphigus and bullous pemphigoid (BP) are autoimmune bullous diseases that predominantly affect middle‐aged and elderly individuals. The gold standard of treatment is oral corticosteroids. Intravenous immunoglobulin (IVIG), plasmapheresis, and various immunosuppressive agents are also used to treat BP. The use of these drugs in older patients is extremely risky in terms of prognosis, because the side effects of them are so severe. Therefore, we, researchers and physician scientists, should aim to elucidate the pathogenesis of pemphigus and BP, and to establish new, safe treatments with fewer adverse effects. In this special issue, we invited leading Japanese pemphigus and BP physician scientists as authors to update us on how far the pathogenesis of pemphigus and BP has been elucidated and what kind of research is being conducted with the aim of establishing new treatment strategies.First, three authors submitted state‐of‐the art reviews about pemphigus. Dr Hayato Takahashi described in detail the T cell–mediated immune breakdown against desmoglein 3 in the elimination as “T‐cell autoimmunity and immune regulation to desmoglein 3, a pemphigus autoantigen.” Furthermore, Dr Jun Yamagami summarized the current status of B cell–targeted therapy, namely, rituximab and Bruton tyrosine kinase inhibitor therapy in “B cell–targeted therapy of pemphigus.” In addition, Dr Norito Ishii summarized in detail the role of anti‐desmocollin antibodies, which are found in atypical pemphigus as “Significance of anti‐desmocollin autoantibodies in pemphigus.”Next, two authors offered reviews on pemphigoid. First, Dr Hideyuki Ujiie described the pathomechanism and trigger of BP in “What's new in the pathogeneses and triggering factors of bullous pemphigoid.” Then, Dr Sho Hiroyasu and our group described the devastating symptom in BP, itch, in “Pruritogens in pemphigoid diseases: possible therapeutic targets for a burdensome symptom.” Furthermore, Dr Yumi Aoyama reported a rare case of bullous pemphigoid.We believe that by understanding all of these reviews and applying them to research and treatment, we will be able to provide state‐of‐the‐art fields in these diseases at a glance. It will be exciting to see what will be elucidated in this rapidly advancing field of research when a similar special issue is published again in a few years. In particular, I hope that we will be able to understand why these diseases occur by elucidating the initial triggering factor within a few years. It is also clear that progress in research on these two diseases will lead to the elucidation of the pathogenesis of other general autoimmune diseases and guide the development of treatments.


Digital health solutions, specifically direct‐to‐consumer platforms, have been touted to make care accessible and convenient for patients. The aim of this article is to evaluate patients' reported reasons for choosing a platform for the treatment of hair loss and their experience. This platform (Keeps) is focused exclusively on the treatment of male pattern hair loss (MPHL) with approved medications such as oral finasteride and topical minoxidil.In order to evaluate patients' motivations to choose the platform and their experience, we administered two distinct questionnaires, with a total of 8983 respondents.The results showed that patients on the platform report positive health outcomes at approximately 6 months, as 81% of respondents report hair regrowth or cessation of hair loss, and 91% never or rarely miss their medication. Additionally, the platform is expanding the market through education and awareness, as nearly 1 in 3 new patients, mostly in their 20s and early 30s, had never considered treating their hair loss before learning about this virtual care model.Such a model provides further insights into how digitally enabled care focused on a chronic condition, backed by quality and evidence‐based initiatives, can expand access and improve care for androgenetic alopecia (AGA). Over 50% of men suffer from male pattern hair loss (MPHL), also known as androgenetic alopecia (AGA). Medical treatments such as finasteride 1 mg and 5% topical minoxidil have been found to be effective in halting, and in some cases reversing, the effects of MPHL.Digital health solutions, specifically direct‐to‐consumer platforms that provide prescription medications after online consultation are expanding in the US.The aim of this paper is to evaluate patients' motivations for choosing an overall experience with the largest direct‐to‐consumer platform providing treatment for MPHL, Keeps, which has over 300,000 active subscribers across the U.S. as of August 2021.The platform care team includes board‐certified dermatologists, internal medicine and family medicine physicians, and customer care specialists/coordinators. Quality of care is monitored by the medical director, a board‐certified dermatologist, who reviews a random sample of 2% of each physician's cases. Review audits of over 2000 cases thus far have demonstrated 100% concordance with the diagnosis of MPHL among patients. The medical director also provides ongoing education to the participating physicians and guidance on complex cases as needed.The patient journey starts via an asynchronous consultation with a physician, which includes scalp photos submitted by the patient. If the diagnosis of MPHL is confirmed, the physician provides a prescription for finasteride 1 mg and/or a recommendation for over‐the‐counter 5% topical minoxidil. The patient is advised to seek an in‐person visit with a dermatologist in case of doubts about the diagnosis or if he is deemed not a match for the available treatments offered by the platform.Patient enrollment for finasteride and/or minoxidil subscription creates automated touchpoints to ensure the treatment has been initiated, and educational materials are provided throughout the patient's journey. This includes information on anticipated timelines for improvement and potential side effects of the treatment. The platform also utilizes a progress tracker tool, which enables patients to upload follow‐up photos periodically during their treatment. The treating physician reviews these photos and provides feedback to the patient regarding his progress and any recommended treatment modifications. Patients also have the ability to send questions to their physicians throughout the course of treatment. These various touchpoints through the virtual care platform, combined with the delivery of medications directly to the patient's doorstep, provide convenient end‐to‐end access to care and aim to enhance patient engagement and adherence to treatment.Two questionnaires were administered via SurveyMonkey to collect self‐reported data from patients at different points in their treatment journey. Responses for Questionnaire A were collected from August 27, 2020, to May 12, 2021. Questionnaire A is sent to every customer with a non‐canceled account 20 days after they place their 3rd order , as treatments typically take at least 4–6 months to demonstrate results for patients. A separate questionnaire (Questionnaire B) was administered to every customer who completed a consultation, received a prescription from a doctor, and whose order has been shipped . Responses for Questionnaire B were collected from December 21, 2020, to February 24, 2021. The list of questions and responses received for both questionnaires are captured in Tables For Questionnaire A, 3359 responses were received out of 64,567 surveys sent (response rate: 5.2%). A sample of 3359 respondents represents 243,261 patients who have stayed on the platform for at least 200 days. At a 95% level of confidence, the margin of error is 1.7%. Given a 100% completion rate for each reported question on Questionnaire A, the margin of error for each individual question is the same as that of the survey at 1.7% at a 95% level of confidence.For Questionnaire B, 5624 responses were received out of 34,441 surveys sent (response rate: 16.3%). A sample of 5624 respondents represents 533,614 patients on our platform who have made at least one purchase. At a 95% level of confidence, the margin of error is 1.3%. Given an upwards of 99% completion rate for each reported question on Questionnaire B, the margin of error for each individual question is the same as that of the survey at 1.3% at a 95% level of confidence.For Questionnaire A, approximately 81% of respondents report positive results, of which 64% report at least some hair regrowth and 36% report cessation of hair loss. Meanwhile, 91% of respondents report never or rarely missing (once per week or less frequently) their medication.Additionally, through Questionnaire B, we found that the platform is expanding the market through education and awareness, as 32% of new patients surveyed, predominantly in the 20 to early 30‐year‐old range, had never considered treating their hair loss before learning about Keeps. The ability to engage patients at an earlier stage of their hair loss journey bodes well for long‐term outcomes.In this paper, we have focused on direct‐to‐consumer platforms for treating MPHL, but many similar platforms exist across a variety of other dermatologic conditions, such as acne and anti‐aging. Access to dermatologic care in the U.S. has been a challenge for many years, based on the overwhelming demand of patients compared to the supply of dermatologists. The utilization of mid‐level dermatology providers under the supervision of dermatologists has only partially filled this gap. The use of virtual care with technology‐driven processes provides an immense opportunity to deliver accessible dermatologic care at a large scale.Direct‐to‐consumer platforms have gained traction over the last several years, with acceleration in the past year due to the Coronavirus pandemic. Telemedicine is an effective option for diagnosing and treating hair disorders, and many patients have felt safer engaging in telehealth visits than in‐person visits throughout the pandemic.The results of this study show the ability of a virtual care platform to extend evidence‐based MPHL treatments to a large patient population, which includes a significant portion of patients who had not considered treating their hair loss until hearing about the platform. Additionally, the results demonstrated the virtual care platform's ability to promote treatment adherence and deliver favorable treatment outcomes for its patients. This study also highlights the importance of dermatologists providing rigorous oversight of direct‐to‐consumer telehealth platforms providing care for dermatologic conditions. This should include robust quality improvement programs, e.g., chart audits, to ensure that high‐quality evidence‐based dermatologic care is provided.While there remain pockets of skepticism and resistance toward direct‐to‐consumer telehealth in the medical community, consumerism will inevitably catalyze further adoption of this model. The dermatology community should continue to monitor the progress of direct‐to‐consumer telehealth platforms, as these may offer important lessons for improving access to high‐quality dermatologic care. In addition to standalone direct‐to‐consumer telehealth companies, there are opportunities to integrate this model into existing dermatology practices in order to improve access and the overall patient experience.The purpose of this study is not to compare online platforms vs in‐person consultations for male androgenetic alopecia but to evaluate the satisfaction of patients who have already chosen the online option and to understand their reasons.Although in‐person evaluation by a dermatologist, including trichoscopy, remains the gold standard for managing male androgenetic alopecia, this study has shown that virtual consultation, if properly organized and monitored, may provide a viable alternative. In addition, the use of teletrichoscopy and teletrichology is a promising new option to interact with hair disorder patients remotely and, if properly performed, is effective in selecting patients who need in‐person consultation for diagnostic or therapeutic procedures.Patients' approach to their medical care has dramatically changed in the last few years, with the increasing role of social media and online medical providers. New generations clearly want to play a more active role in the choice of their medical care. We believe it is important for dermatologists to understand the new online and virtual healthcare options, as well as patient preferences and motivations that drive their decisions when seeking medical care and advice.There is a possibility of non‐response bias as patients who chose not to respond to questionnaire A could differ in their satisfaction from those who responded. However, since all patients who were sent the questionnaire needed to have placed multiple orders and have been active on the platform for over 6 months, it is reasonable to assume that non‐respondents are satisfied enough to continue with their treatment. A similar limitation of non‐response bias applies to questionnaire B as well. However, since questions of interest centered around attitudes toward Keeps vs. traditional medical practice, and we report attitudes of patients who ultimately purchased a Keeps product, it is likely that respondents would be similar to non‐respondents.


Lithobates sylvaticus) tadpoles and spotted salamander (Ambystoma maculatum) eggs as a model system, we tested three hypotheses: (1) having the outer jelly layers would be costly to the embryos, (2) the relative benefit of the structural egg defense would become apparent and increase as the intensity of egg predation increases, and (3) a certain degree of predation would increase the hatching success of salamander embryos by mechanically thinning the thick outer jelly layers and increasing oxygen diffusion throughout an egg mass. To test these hypotheses, we conducted a factorial experiment in which we crossed four egg‐predation levels with two jelly‐layer conditions, intact or removed. We found that the jelly layers were essential in protecting spotted salamander embryos from wood frog tadpoles but that the associated cost was apparent in no‐predation treatments. The differential survivorship between intact eggs and eggs without jelly layers showed that the fitness advantage of jelly layers increased as the level of predation increased. Finally, the hatching success of intact egg masses was highest under the high predation conditions. These results imply that the evolution of the jelly‐layer thickness occurred under constant egg‐predation pressure. Given this predator–prey coevolution, egg predators may play a critical role in improving the hatching success of salamander embryos under certain conditions.A common challenge that oviparous animals face is securing survivorship during the vulnerable embryonic stage. One of the parental investment strategies to improve survivorship is providing physical structures to protect the embryos. In amphibians, there is a notable diversity in jelly‐layer structures surrounding eggs. Previous studies show that these jelly layers provide eggs with protection against egg predators, egg pathogens, and desiccation. However, few studies examined the cost–benefit relationship of the jelly‐layer structures. By using the predator–prey interaction between wood frog ( A common challenge that oviparous animals face is securing survivorship during the vulnerable embryonic stage. One of the parental investment strategies to improve survivorship is providing physical structures to protect the embryos. We found a cost associated with the protective jelly layers surrounding the spotted salamander embryos, which egg predators mitigated. We conducted sample collection under the scientific collection permit issued by the Pennsylvania Fish and Boat Commission.2.2A. maculatum) and the wood frog (L. sylvaticus) are common pond‐breeding amphibians throughout their distribution ranges in northeastern America. Our field collection site  is located within the core region of the distribution ranges. During the spring of 2015, we monitored several forested vernal ponds daily. We collected the freshly laid egg masses of spotted salamanders on April 4 after the major breeding event a day before, ensuring that all egg masses were the same age. Egg masses of spotted salamanders come in two morphs, white and clear, and we used white egg masses because the white morph is dominant in this region. The collected egg masses were individually housed in 7.2 L rectangle plastic containers half‐filled with pond water (container size: 28 cm [L] × 15 cm [W] × 11 cm [H]) under 10°C and a 12 h light and 12 h dark cycle. After we processed the salamander egg masses and prepared them for the experiment, we collected wood frog tadpoles from the same vernal pond on April 24.The spotted salamander . We then gently removed jelly layers by hand from half of the egg masses and recorded the number of embryos of each . We estimated the number of embryos of the remaining intact egg masses based on the linear regression formula between the number of embryos and the weight of the egg mass from those without jelly layers , and two levels of jelly‐layer manipulation (intact or removed). We replicated each of the six treatments four times, resulting in 32 experimental units. We blotted each egg mass with paper towels and weighed each .On April 25, after confirming that exposed embryos were developing normally, we began the experiment by adding wood frog tadpoles to 16 containers pre‐assigned for the predation treatments. We calculated the average number of spotted salamander embryos per egg mass  and set the number of tadpoles in each predator treatment as 0 tadpoles (no predation), 50 tadpoles (low predation), 100 tadpoles (medium predation), or 200 tadpoles (high predation). We then adjusted the actual number of tadpoles added to each container based on the number of embryos in a given container. The range of the tadpole number varied from 0 to 272 per container with an area of 710 cmTadpoles in a natural pond have unlimited access to leaf litter as food. Thus, we fed tadpoles weekly with rabbit food ad‐lib. We also cleaned off excess food and excrement and performed a 50% water change of all containers weekly. The temperature in the growth chamber was kept at 10°C until May 18th and then was raised to 15°C to simulate a rapidly rising spring temperature in the field. We monitored all containers daily and recorded any hatchlings to calculate hatching success (the number of hatchlings divided by the number of embryos) and embryonic period per container. Developmental stages and sizes of hatchlings were not recorded because hatchlings were used for another experiment, and taking precise measurements of these traits would have required euthanization. We terminated the experiment on June 8 when all embryos had hatched out or been consumed by tadpoles. In one container assigned for high predation with jelly layers, the actual number of hatchlings was greater than the estimated number of embryos based on the linear regression formula. Thus, we corrected the survivorship of this egg clutch to 1.2.4y · (n − 1) + 0.5)/n] where n is the sample size . Hatching success under no predation treatment was greater than the rest of the predation treatments  and intact egg masses overall resulted in better hatching success than egg without jelly‐layers . Furthermore, there was a strong interactive effect between the predation and jelly‐layer manipulation . Post‐hoc tests revealed that the hatching success of egg clutches without jelly layers was highest under no predator treatment, followed by that under low predator treatment, while no embryos without jelly layers successfully emerged under medium or high predator treatment . In contrast, intact egg masses achieved the highest hatching success under high predation . There were no significant differences in the hatching success of intact egg masses among no, low, and medium predator treatments.In total, 1401 hatchlings successfully emerged from 32 egg clutches . Overall hatching success in the absence of predations (no predation: 81.5% ± 4.4) was similar to the values reported from a previous lab experiment . In low, medium, and high predation, hatching success was significantly greater in intact eggs . As a result, the differential survivorship, which was defined as (hatching success of intact egg mass) − (hatching success of egg mass without jelly layers), increased as the predation intensity increased . Although there was a trend of earlier hatching from intact egg masses under greater predation pressure .Because there was no successful hatching from egg clutches without jelly layers under medium and high predation treatments, there was no embryonic period data from those treatments. Even without the data from those treatments, we found significant effects of predation treatment and jelly‐layer manipulation as well as the interactive effect between the two main effects  were used as predators along with other insect predators . Building onto these studies showing the cost of the protective jelly layers under unfavorable conditions, our study shows that the cost still exists under normal light conditions. In addition to the cost associated with oxygen diffusion, we observed dead embryos often positioned in the center of the egg mass, and they appeared developmentally ready to hatch. This may suggest greater oxygen demand as embryos develop more, resulting in mortality later in the embryonic developmental stages. It is also possible that thick jelly layers physically challenge the hatching of embryos. Overall, evidence from the previous and present studies suggests that the cost of having thick protective layers can impose tangible adverse effects on the hatching success of spotted salamander embryos under the range of naturally occurring conditions.A major factor contributing to the cost associated with the jelly layers was likely to be the hindrance of oxygen diffusion among the embryos Kerney, . This cop = .9912); these two treatments achieved the highest hatching success among all eight treatment groups  and the Marbled salamander (A. opacum) are two congenic pond‐breeding salamanders which are commonly found with the spotted salamander and the wood frog throughout much of their distribution ranges. The Jefferson salamander breeds earlier in the spring than the spotted salamander and other pond‐breeding frogs. By the time tadpoles become large enough to forage the spotted salamander egg masses, the majority of the Jefferson salamander eggs have already hatched. The thickness of the Jefferson salamander egg masses is notably thinner than those of the spotted salamander. The Marbled salamander breeds in the fall on land immediately adjacent to a pond, the egg clutch is then guarded by the female, and the eggs hatch in late fall when they are flooded with pond water. In this species, the risk of egg predation is presumably much lower, and no outer jelly layers surround individual egg capsules. In this way, the family Ambystomadae, containing 32 species with vastly different jelly‐layer arrangements ; data curation (supporting); formal analysis (lead); investigation (lead); methodology ; project administration (lead); visualization (lead); writing – original draft (lead); writing – review and editing (supporting). Dominique Ruszala: Conceptualization (supporting); data curation (lead); formal analysis (supporting); investigation (lead); methodology ; project administration (supporting); visualization (supporting); writing – original draft (supporting); writing – review and editing (lead).None.None.