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BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology. METHODS: Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first-time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine-Gray regression. RESULTS: A total of 16 143 patients were identified of whom 7.0% (n = 1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p < 0.01) and were more likely to undergo transplantation (75.3% vs. 70.3%, p < 0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p < 0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p < 0.01) and hypertrophic CMP (SHR: 9.78, p < 0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p < 0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p = 0.03). CONCLUSIONS: The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision-making surrounding candidacy for cannulation and prognostic evaluation.
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Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Transplante de Coração , Listas de Espera , Humanos , Oxigenação por Membrana Extracorpórea/mortalidade , Transplante de Coração/mortalidade , Masculino , Listas de Espera/mortalidade , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Prognóstico , Seguimentos , Taxa de Sobrevida , Fatores de Risco , Sistema de Registros , Adulto , Obtenção de Tecidos e ÓrgãosRESUMO
This research note provides new evidence consistent with systemic anti-Black racism in police killings across the United States. Data come from the Mapping Police Violence Database (2013-2021). I calculate race-specific odds and probabilities that victims of police killings exhibited mental illness, were armed with a weapon, or attempted to flee the scene at the time of their killing. Multilevel, multivariable logistic regression techniques are applied to further account for the victim's age, gender, year of killing, and geographical clustering. I find that White victims are underrepresented, and Black victims overrepresented in the database. Relative to White victims, Black victims also have 60% lower odds of exhibiting signs of mental illness, 23% lower odds of being armed, and 28% higher odds of fleeing. Hispanic victims exhibit 45% lower odds of being armed relative to their White peers but are otherwise comparable. These patterns persist regardless of the victim's age, gender, year of killing, or geographical location (zip code, state, and neighborhood type). Thus, the threshold for being perceived as dangerous, and thereby falling victim to lethal police force, appears to be higher for White civilians relative to their Black or Hispanic peers. Current findings provide empirical support for political initiatives to curb lethal police force, as such efforts could help to reduce racial disparities in deaths by police nationwide.
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Scholars cite racist political-economic systems as drivers of health inequities in the United States (i.e., racial capitalism). But how does racial capitalism generate health inequities? I address this open question within the historical context of predatory lending during the 2008 financial crisis. Relevant hypotheses are tested with multiple waves of data from Black and White participants of the National Longitudinal Study of Adolescent to Adult Health (N = 8,877). Across socioeconomic strata, I find that Black participants report higher rates of foreclosure, eviction, repossession, delinquent bills, lost income, and new debts in the wake of the financial crisis. Using structural equation and quasi-experimental models, I then show that Black participants also self-report rapid health declines and increases in prescription drug abuse throughout this period, much of which is explained by chronic financial stress. I conclude that racial capitalism can generate health inequities by ensnaring Black Americans in a toxic web of financial exploitation and stress proliferation.
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Climate change is restructuring biodiversity on multiple scales and there is a pressing need to understand the downstream ecological and genomic consequences of this change. Recent advancements in the field of eco-evolutionary genomics have sought to include evolutionary processes in forecasting species' responses to climate change (e.g., genomic offset), but to date, much of this work has focused on terrestrial species. Coastal and offshore species, and the fisheries they support, may be even more vulnerable to climate change than their terrestrial counterparts, warranting a critical appraisal of these approaches in marine systems. First, we synthesize knowledge about the genomic basis of adaptation in marine species, and then we discuss the few examples where genomic forecasting has been applied in marine systems. Next, we identify the key challenges in validating genomic offset estimates in marine species, and we advocate for the inclusion of historical sampling data and hindcasting in the validation phase. Lastly, we describe a workflow to guide marine managers in incorporating these predictions into the decision-making process.
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Biodiversidade , Pesqueiros , Oceanos e Mares , Genômica , Mudança Climática , Ecossistema , PrevisõesRESUMO
Does anti-Black racism harm White Americans? We advance hypotheses that address this question within the neighborhood context. Hypotheses are tested with neighborhood and survey data from a probability sample of White residents of Nashville, Tennessee. We find that regardless of neighborhood crime rates or socioeconomic compositions, Whites report heightened perceptions of crime and danger in their neighborhoods as the proportion of Black residents increases. Perceived neighborhood danger, in turn, predicts increased symptoms of psychophysiological distress. When stratified by socioeconomic status (SES), however, low-SES Whites also report perceptions of higher status when living near more Black neighbors, which entirely offsets their distress. We conclude that although anti-Black racism can ironically harm the health of White Americans, compensatory racist ideologies can also offset these harms, particularly for lower-status Whites. We situate our findings within broader discussions of anti-Black racism, residential segregation, and psychiatric disorders commonly observed among White Americans.
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Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.
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Oxigenação por Membrana Extracorpórea , Transplante de Pulmão , Resultado do Tratamento , Oxigenação por Membrana Extracorpórea/efeitos adversos , Estudos Retrospectivos , Transplante de Pulmão/efeitos adversos , Modelos de Riscos ProporcionaisRESUMO
The cluster of differentiation 36 (CD36) domain defines the characteristic ectodomain associated with class B scavenger receptor (SR-B) proteins. In bilaterians, SR-Bs play critical roles in diverse biological processes including innate immunity functions such as pathogen recognition and apoptotic cell clearance, as well as metabolic sensing associated with fatty acid uptake and cholesterol transport. Although previous studies suggest this protein family is ancient, SR-B diversity across Eukarya has not been robustly characterized. We analyzed SR-B homologs identified from the genomes and transcriptomes of 165 diverse eukaryotic species. The presence of highly conserved amino acid motifs across major eukaryotic supergroups supports the presence of a SR-B homolog in the last eukaryotic common ancestor. Our comparative analyses of SR-B protein structure identify the retention of a canonical asymmetric beta barrel tertiary structure within the CD36 ectodomain across Eukarya. We also identify multiple instances of independent lineage-specific sequence expansions in the apex region of the CD36 ectodomain-a region functionally associated with ligand-sensing. We hypothesize that a combination of both sequence expansion and structural variation in the CD36 apex region may reflect the evolution of SR-B ligand-sensing specificity between diverse eukaryotic clades.
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Antígenos CD36 , Eucariotos , Antígenos CD36/genética , Antígenos CD36/química , Antígenos CD36/metabolismo , Ligantes , Filogenia , Receptores Depuradores Classe B/metabolismo , Eucariotos/metabolismoRESUMO
Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) comprise a spectrum of neurodegenerative diseases linked to TDP-43 proteinopathy, which at the cellular level, is characterized by loss of nuclear TDP-43 and accumulation of cytoplasmic TDP-43 inclusions that ultimately cause RNA processing defects including dysregulation of splicing, mRNA transport and translation. Complementing our previous work in motor neurons, here we report a novel model of TDP-43 proteinopathy based on overexpression of TDP-43 in a subset of Drosophila Kenyon cells of the mushroom body (MB), a circuit with structural characteristics reminiscent of vertebrate cortical networks. This model recapitulates several aspects of dementia-relevant pathological features including age-dependent neuronal loss, nuclear depletion and cytoplasmic accumulation of TDP-43, and behavioral deficits in working memory and sleep that occur prior to axonal degeneration. RNA immunoprecipitations identify several candidate mRNA targets of TDP-43 in MBs, some of which are unique to the MB circuit and others that are shared with motor neurons. Among the latter is the glypican Dally-like-protein (Dlp), which exhibits significant TDP-43 associated reduction in expression during aging. Using genetic interactions we show that overexpression of Dlp in MBs mitigates TDP-43 dependent working memory deficits, conistent with Dlp acting as a mediator of TDP-43 toxicity. Substantiating our findings in the fly model, we find that the expression of GPC6 mRNA, a human ortholog of dlp, is specifically altered in neurons exhibiting the molecular signature of TDP-43 pathology in FTD patient brains. These findings suggest that circuit-specific Drosophila models provide a platform for uncovering shared or disease-specific molecular mechanisms and vulnerabilities across the spectrum of TDP-43 proteinopathies.
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Esclerose Lateral Amiotrófica , Demência Frontotemporal , Doença de Pick , Proteinopatias TDP-43 , Animais , Humanos , Esclerose Lateral Amiotrófica/patologia , Proteínas de Ligação a DNA/genética , Proteínas de Ligação a DNA/metabolismo , Drosophila/metabolismo , Demência Frontotemporal/genética , Demência Frontotemporal/patologia , Neurônios Motores/metabolismo , Doença de Pick/patologia , RNA Mensageiro , Proteinopatias TDP-43/patologiaRESUMO
Suicide is a public health problem and one of the leading causes of death in the United States. Research exploring the linkages between religion and spirituality has received intermittent attention. Data was derived from the Nashville Stress and Health Study (2011-2014), a cross-sectional probability survey of black and white adults from Davidson County, Tennessee (n = 1252). Results indicate that those with no perceived belief in divine control had a higher likelihood of suicidality. This study provides a fresh perspective on the links between religious factors and suicidality by (a) considering multiple religious and spiritual domains and (b) focusing on the association between irreligion and suicidality.
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Suicídio , Adulto , Humanos , Estados Unidos/epidemiologia , Estudos Transversais , Ideação Suicida , Religião , Espiritualidade , Fatores de RiscoRESUMO
BACKGROUND: According to Digital Health Canada 2013 eSafety Guidelines, an estimated one-third of patient safety incidents following implementation of clinical information systems (CISs) are technology-related. An eSafety checklist was previously developed to improve CIS safety by providing a comprehensive listing of system-agnostic, evidence-based configuration recommendations. OBJECTIVES: We sought to use the checklist to support safe initial configuration of a provincial system-wide CIS (Alberta, Canada), referred to as Connect Care. METHODS: The checklist was applied to 13 Connect Care modules in three successive phases. First, the checklist was adapted to an abbreviated high-priority version. Second, demonstrations of each module were recorded. Finally, independent evaluation of each recording was conducted by two eSafety evaluators using the abbreviated eSafety checklist. RESULTS: All modules achieved greater than 72% compliance, with an average of 84%. Overall, 273 opportunities for improvement were identified, with four major areas or themes emerging: (1) inconsistent date and time, (2) unclear patient identification, (3) ineffective alert system, and (4) insufficient decision support. These opportunities were forwarded to the appropriate build teams for review and implementation. CONCLUSION: This work is the first to utilize the eSafety checklist in a real-world CIS, which will become one of the largest in Canada. The checklist has shown clinical applicability in identifying gaps in CIS configuration and should be considered for use in future and pre-existing CISs.
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Lista de Checagem , Cooperação do Paciente , Humanos , Canadá , Segurança do Paciente , Sistemas de InformaçãoRESUMO
Most commercial flue-cured tobacco cultivars contain the Rk1 resistance gene, which provides resistance to races 1 and 3 of Meloidogyne incognita and race 1 of M. arenaria. A number of cultivars now possess a second root-knot resistance gene, Rk2. High soil temperatures have been associated with a breakdown of root-knot resistance genes in a number of crops. Three greenhouse trials were performed from 2014 to 2015 investigate the effect of high soil temperature on the efficacy of Rk1 and/or Rk2 genes in reducing parasitism by a population of M. incognita race 3. Trials were arranged in randomized complete block design in open-top growth chambers set at 25°, 30°, and 35°C. Plants were inoculated with 3,000 eggs and data were collected 35 days post-inoculation. Galling, numbers of egg masses and eggs, and reproductive index were compared across cultivar entries. Nematode reproduction was reduced at 25°C and 30°C on entries possessing Rk1 and Rk1Rk2 compared to the susceptible entry and the entry possessing only Rk2. However, there were often no significant differences in reproduction at 35°C between entries with Rk1 and/or Rk2 compared to the susceptible control, indicating an increase of root-knot nematode parasitism on resistant entries at higher temperatures. Although seasonal differences in nematode reproduction were observed among experiments, relative differences among tobacco genotypes remained generally consistent.
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We report here the design and development of a method for the single-step conversion of esters to ketones with simple reagents. The selective transformation of esters to ketones, rather than tertiary alcohols, is made possible by the use of a transient sulfinate group on the nucleophile that activates the adjacent carbon toward deprotonation to form a carbanion that adds to the ester, followed by a second deprotonation to prevent further addition. The resulting dianion undergoes spontaneous fragmentation of the SO2 group upon quenching with water to reveal the ketone product.
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Steatotic livers represent a potentially underutilized resource to increase the donor graft pool; however, 1 barrier to the increased utilization of such grafts is the heterogeneity in the definition and the measurement of macrovesicular steatosis (MaS). Digital imaging software (DIS) may better standardize definitions to study posttransplant outcomes. Using HALO, a DIS, we analyzed 63 liver biopsies, from 3 transplant centers, transplanted between 2016 and 2018, and compared macrovesicular steatosis percentage (%MaS) as estimated by transplant center, donor hospital, and DIS. We also quantified the relationship between DIS characteristics and posttransplant outcomes using log-linear regression for peak aspartate aminotransferase, peak alanine aminotransferase, and total bilirubin on postoperative day 7, as well as logistic regression for early allograft dysfunction. Transplant centers and donor hospitals overestimated %MaS compared with DIS, with better agreement at lower %MaS and less agreement for higher %MaS. No DIS analyzed liver biopsies were calculated to be >20% %MaS; however, 40% of liver biopsies read by transplant center pathologists were read to be >30%. Percent MaS read by HALO was positively associated with peak aspartate aminotransferase (regression coefficient= 1.04 1.08 1.12 , p <0.001), peak alanine aminotransferase (regression coefficient = 1.04 1.08 1.12 , p <0.001), and early allograft dysfunction (OR= 1.10 1.40 1.78 , p =0.006). There was no association between HALO %MaS and total bilirubin on postoperative day 7 (regression coefficient = 0.99 1.01 1.04 , p =0.3). DIS provides reproducible quantification of steatosis that could standardize MaS definitions and identify phenotypes associated with good clinical outcomes to increase the utilization of steatite livers.
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Fígado Gorduroso , Processamento de Imagem Assistida por Computador , Transplante de Fígado , Humanos , Alanina Transaminase , Aspartato Aminotransferases , Bilirrubina , Biópsia , Fígado Gorduroso/diagnóstico por imagem , Fígado Gorduroso/patologia , Fígado/diagnóstico por imagem , Fígado/patologia , Transplante de Fígado/métodos , Software , Processamento de Imagem Assistida por Computador/métodosRESUMO
BACKGROUND: Inflammatory bowel disease (IBD) and pregnancy both impact health-related quality of life (HRQoL). However, little is known about IBD-related HRQoL around pregnancy. AIMS: To assess the trajectory and predictors of HRQoL in preconception and pregnant patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS: Preconception and pregnant patients with IBD were followed prospectively from preconception to twelve months postpartum at a tertiary referral centre. Participants completed the Short IBD Questionnaire (SIBDQ) and were assessed for clinical disease activity (modified Harvey Bradshaw Index or partial Mayo score) and objective disease activity (C-reactive protein [CRP], fecal calprotectin [FCP]). RESULTS: A total of 61 patients with IBD (25 CD, 36 UC) were included. During preconception, patients with UC had higher SIBDQ bowel and social sub-scores than those with CD, but this reversed during postpartum. Patients with CD but not UC developed a significant, sustained improvement in SIBDQ upon becoming pregnant, which persisted into 12 months postpartum. In a multivariable linear regression model, clinical disease activity negatively predicted SIBDQ at every pregnancy timepoint and up to 12 months postpartum. SIBDQ was significantly lower in patients with CRP ≥ 8.0 mg/L during trimester 1 (T1), but not later in pregnancy. SIBDQ bowel sub-scores were significantly lower in patients with FCP ≥ 250 mg/kg at T2, T3, and 6 months postpartum. CONCLUSIONS: Clinical disease activity is a consistent negative predictor of HRQoL from conception to 12 months postpartum. Patients with UC experience better preconception HRQoL but suffer worse postpartum HRQoL than those with CD.
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Colite Ulcerativa , Doença de Crohn , Doenças Inflamatórias Intestinais , Gravidez , Feminino , Humanos , Qualidade de Vida , Doença de Crohn/diagnóstico , Colite Ulcerativa/diagnóstico , Proteína C-Reativa , Inquéritos e Questionários , Índice de Gravidade de DoençaRESUMO
A growing body of work links neighborhood conditions -and particularly perceived neighborhood disorder-with diverse aspects of psychosocial functioning, including self-esteem or the global moral self-worth of the individual. Our work augments this literature by investigating the possible roles of (a) organizational religiosity (i.e., religious attendance, religious support), (b) non-organizational religiosity (i.e., prayer and religious coping practices), and (c) the sense of divine control as potential stress in mitigating the deleterious effects of neighborhood disorder on self-esteem. Data from the Nashville Stress and Health Study (NSAHS, 2011-2014) are used to test a series of hypotheses regarding the possible stress-buffering effects of multiple religious domains. Findings from multivariable regression models indicate that: (a) perceived neighborhood disorder is inversely associated with self-esteem; (b) non-organizational religiosity and the sense of divine control each mitigate this pattern; and, interestingly, (c) organizational religiosity does not buffer the association between neighborhood disorder and self-esteem. Several study limitations, as well as a number of promising directions for future research, are identified.
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Background: Although religious involvement tends to be associated with improved mental health, additional work is needed to identify the specific aspects of religious practice that are associated with positive mental health outcomes. Our study advances the literature by investigating how two unique forms of religious social support are associated with mental health. Purpose: We explore whether support received in religious settings from fellow congregants or religious leaders is associated with participants' mental health. We address questions that are not only of interest to religion scholars, but that may also inform religious leaders and others whose work involves understanding connections between religious factors and psychological outcomes within religious communities. Methods: We test several hypotheses using original data from the "Mental Health in Congregations Study (2017-2019)", a survey of Christian and Jewish congregants from South Texas and the Washington DC area (N = 1882). Surveys were collected using both paper and online surveys and included an extensive battery of religious and mental health measures. Results: Congregant support has more robust direct associations with mental health outcomes than faith leader support. Increased congregant support is significantly associated (p < 0.001) with fewer symptoms of psychological distress (ß = - 0.168), anxiety (ß = - 0.159), and anger (ß = - 0.190), as well as greater life satisfaction (ß = 0.269) and optimism (ß = 0.283). However, faith leader support moderates these associations such that congregant support is associated with better mental health only in cases where faith leader support is also high. When leader support is low, congregant support and mental health are not associated. Conclusions and Implications: At the conceptual level, our study adds to an extensive literature on the relationship between religious social support and mental health. Additionally, our work may provide important insights to religious leadership in terms of communications strategies, services, and resources that might enhance overall congregant mental health and well-being.
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This study addresses two questions. First, why do Black Americans exhibit worse health outcomes than White Americans even at higher levels of socioeconomic status (SES)? Second, are diminished health returns to higher status concentrated among Black Americans with darker skin color? Novel hypotheses are tested with biosocial panel data from Add Health, a nationally representative cohort of Black and White adolescents who have transitioned to adulthood. We find that White and light-skin Black respondents report improved health after achieving higher SES, on average, while their darker-skin Black peers report declining health. These patterns persist regardless of controls for adolescent health status and unmeasured between-person heterogeneity. Moreover, increased inflammation tied to unfair treatment and perceptions of lower status helps to account for patterns of diminished health returns for dark-skin Black groups. Our study is the first to document skin tone heterogeneity in diminished health returns and one of few studies to identify life course stress processes underlying such disparities. We consider additional processes that could be examined in future studies, as well as the broader health and policy implications of our findings.
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Pigmentação da Pele , População Branca , Adolescente , Adulto , Negro ou Afro-Americano , População Negra , Humanos , Classe SocialRESUMO
Trimodal therapy (TMT) - maximal transurethral resection of bladder tumour followed by chemotherapy and radiation - is an effective treatment for some patients diagnosed with muscle-invasive bladder cancer. Yet eligible patients are not always offered this option or are unclear that this option is (or was) appropriate, desirable and available to them. Communication challenges are a critical barrier to delivering the high-quality care and shared decision-making that bladder cancer patients seek. Leveraging patient and clinician feedback, a checklist was created and is proposed that proactively addresses patients' concerns and questions and ensures that patients are well-informed about TMT. By using the checklist, members of multidisciplinary bladder cancer medical teams can ensure that patients are well-informed about TMT and are confident that TMT has been appropriately and jointly explored as a treatment option. The checklist can reduce communication challenges and frustrations and ensure that, through shared decision-making, patients have chosen their most appropriate treatment.
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Cistectomia , Neoplasias da Bexiga Urinária , Lista de Checagem , Terapia Combinada , Comunicação , Humanos , Invasividade Neoplásica/patologia , Defesa do Paciente , Bexiga Urinária , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgiaRESUMO
At all levels of socioeconomic status, Black Americans can expect to live shorter and sicker lives than their White counterparts. This study advances the perspective that anti-Black stigma from Whites precludes Blacks from reaping the full health rewards of higher status, particularly within the context of neighborhoods. To test this hypothesis, I merge census data with rich survey and biomarker data from the Nashville Stress and Health Study, a representative sample of Black and White adults from Davidson County, Tennessee (n = 1,252). Initially, I find that Blacks who reside in higher-status and mostly White communities exhibit lower levels of neuroendocrine stress hormones, relative to their peers living in disadvantaged Black neighborhoods. But Blacks in higher-status areas also report more perceived discrimination. In turn, perceived discrimination is associated with chronic bodily pain, as well as elevated stress hormones and blood pressure tied to high goal-striving stress, or fears of being blocked from reaching life goals. After accounting for racism-related stressors, Blacks exhibit comparable levels of physiological distress regardless of neighborhood context. The inverse is true for Whites, who report fewer stressors in higher-status neighborhoods, and less physiological distress than Blacks overall. Findings are discussed within the context of social evolutionary theories of the human brain and are dovetailed with broader racial health disparities in the United States.