Vodafone Spain has signed up to provide Netflix on its platform, the first such deal struck by the streaming video provider in the country.Using the Netflix app, Vodafone TV homes will be able to watch Netflix content through their set–top box. Netflix will be available through Vodafone TV when Netflix launches in Spain in October.The Netflix offering will include exclusive original series such as Narcos, Marvel’s Daredevil, Sense8, Bloodline, Grace and Frankie, Unbreakable Kimmy Schmidt and Marco Polo and critically acclaimed documentaries Virunga, Mission Blue and docuseries Chef’s Table as well as various stand–up comedy specials.Additionally, younger viewers will find a selection of programming for kids.Viewers will also be able to watch Netflix’s new Original feature films, with announced titles including Beasts of No Nation, Crouching Tiger, Hidden Dragon The Green Legend, Jadotville and The Ridiculous 6.Netflix in Spain is fully localised, offering a choice of subtitles and dubbing.Netflix will be available on Vodafone TV through an app on the decoder. Viewers will also be able to find titles using the search engine or recommendations section of the Vodafone service. According to Netflix, Vodafone customers will be able to enjoy Netflix in high quality thanks to a collaboration between the companies on Vodafone’s ultra high–speed fixed and mobile broadband networks.Vodafone TV customers will be able to enjoy the Netflix service without having to update their set–top–boxes. Netflix will also be available on smartphones and tablets. The Netflix app for those devices will be available in the app stores.
Global pay TV revenue growth slowed significantly last year, with North American revenues peaking in 2015 and emerging markets contributing much of the growth between 2010 and 2016, according to new research.According to Digital TV Research’s Global Pay TV Revenue Databook, pay TV revenues across 138 countries increased by US$32 billion (€29 billion) between 2010-2016. However, pay TV revenue growth in 2016 amounted to only US$1.23 billion.Digital TV Research principal analyst Simon Murray said that North American pay TV revenues, which grew by US$7.516 billion between 2012-2016, peaked in 2015 and actually declined by US$1.77 billion last year.The Asia Pacific region, on the other hand, added US$10.21 billion between 2010 and 2016, up by 42% to US$34.38 billion. Latin America increased by 78% to US$18.44 billion. Sub-Saharan Africa more than doubled its total to US$4.20 billion.The US accounted for 49.5% global pay TV revenues in 2016; slipping below the halfway point for the first time. The country’s share of the global total in 2010 was 54.5%, according to Digital TV Research’s numbers.Five countries – the US, China, the UK, Japan and Canada – accounted for two third of global pay TV revenues last year.Half of the growth between 2010 was generated by the US, China, Brazil and India. Nine countries reported declines over the same period, mostly due to subscribers converting from standalone TV services to bundles with other products.Overall, pay TV revenues more than doubled in 59 countries over the reported period.
If you have not read the first three parts of this series, please do that first: They are a necessary prelude: Westphalian Orders’ End Part 1 Westphalian Orders’ End Part 2 Westphalian Orders’ End Part 3 I have thus far made quite a few arguments why the Westphalian order of states is in trouble. Presuming that I am correct, and that the current state model fails, the great question is what comes next? The Two Classes Impolitic though it may be, any sensible analysis of states in transition has to divide the inhabitants into two groups: the Rulers and the Ruled. We can seek tamer terms if we like (such as officials and citizens), but those terms invariably muddle the issue. There are two groups that matter: those that make orders and those who take orders. These two face massively different challenges and incentives; separating them clearly is the only way to arrange a reasonable discourse. I will begin with the rulers: Imagine being a big boss of a big country: You and your predecessors have promised free everything to your voters, but you have now failed to deliver. They are angry, but there’s nothing you can do; there are no more buyers for your bonds and inflation has made your currency almost worthless. You are out of options. At the same time, you can’t just walk away – being the boss is something you need. So, what do you do? Your first job will be to keep the people with you, rather than against you. You must give them someone else to blame and to make them feel horrible about the prospect of your system vanishing. Finding outsiders to blame is always easy. (Jews and immigrants being the perennial favorites.) Making people feel like they need you, however, isn’t so easy, especially when your promises have just come up painfully short. You need some majestic promise for them to believe in: something that makes them special, provides a credible promise of more than they deserve, and/or makes them part of some magical uber-entity. In other words, you need an appealing new myth. The problem, of course, is that large new myths are not created in a day, and certainly not by people who can’t deliver much. So, you have to use whatever respected myths remain, make them more grandiose, and run with them. (This is precisely what happened at the end of the Roman Empire, as I will explain in Free-Man’s Perspective.)Fall of the Roman Empire Right now, the only big myths are of the globalist strain, such as climate change, save the rainforest (or whales, or trees, or children, or…), the value of politically correct speech and so on. Judeo-Christianity remains, of course, but it is a horrible mythology from a ruler’s point of view, is more or less incompatible with the globalist myths, and has been driven from respectable circles in most of the west anyway. So, the mythologies chosen by the rulers will have to be based upon environmentalism, anti-capitalism, and associated guilt-centric ideas. For lack of a better term, the new mythology will probably have to be globalist, with the many nation states and their scattered strategies being blamed for the crisis. The solution to the crisis, of course, will almost certainly be unified management by proper elites. But if globalist, elite rule is to be the next model, a modification of the social contract will be necessary. This will be the great moment of opportunity for intellectuals. Devising a legitimacy myth for the new order will be a ticket to fame and fortune. As strange as it sounds, there is another group associated with the rulers that must be included in this discussion, and they are the dependent class. People who survive on government checks are not what we usually think of as rulers, but they are necessarily joined to them. Together with the elites, they form a high-low ruling coalition. The vast majority of the dependent will support the rulers (or at least the replacement rulers), almost regardless of what the rulers do. Even if their checks stop, promises of future checks will keep them faithful. The other choice is to utterly reform their lives, and very few will be of any mind to do so. They may complain or even riot at the moment when their checks stop, but being faced with either radical change or supporting the rulers and hoping for restoration, they will choose the latter. And, most unfortunately, this is a very large group. The Other Side Now – and this will not be hard for most of my readers – imagine that you have behaved well and worked hard; that, after being challenged by numerous obstacles, you have carved out a comfortable, stable life. Then imagine that it has been turned upside down. Everything is a mess, and you want things to get back to normal so you can work and enjoy life. What do you do? This is where the formation of the future gets interesting. The Rulers may come up with a few surprises, but their strategies are more or less predictable. The productive ruled, however, are a wild card. Ultimately, they control everything, but they don’t know it. Rulers do not make, they only take. The productive make. If they ever decided, en masse, to stop giving in to the rulers, the rulers would be soundly defeated, and in short order. No matter how many armed tax collectors they employed, it wouldn’t be enough for an unwilling populace, not to mention that paying the armed collectors gets very difficult when there is no more money coming in. And if the mechanic refuses to fix state vehicles, if the HVAC man refuses to fix their air conditioning, and so on, the end comes much faster. The above is precisely what happened at the end of the Roman Empire: Harsher and harsher tax laws brought in less and less silver. People ran away to Germania, Britannia and Gaul to escape. The ruling structure failed. But, as mentioned above, the productive middle does not believe that they have the right to make their own political decisions; they feel free to choose between Party A and Party B, but not to demand a new structure. If, somehow, the productive class does decide they are worthy of such choices, it will be a small matter for them to begin organizing with their neighbors, cobbling together ground-up systems of law and markets, and arriving, over time, at a structure that suits them. They would almost certainly end up rediscovering John Locke, the common law, and sound money. But will they? The Cognitive War Though most of us have seldom realized it, we have been living through a continual war for our minds and our wills. We feel confused a great deal and suspect that it is our own problem; a problem that we hide, rather than risking shame. This equates, roughly, to a surrender in the cognitive war. Anyone who seeks to make us do things without thinking, wages war against our wills. Whole industries are built on this, as we all know: “Look at the pretty, happy people; buy the beer,” “don’t vote for that horrible, scary candidate,” “look here at the sexy girl,” and so on. We all swim in a soup of it. This battle will determine what comes out of Westphalia’s crisis. If the Lockean productive class is too confused and intimidated to assert their wills, the globalists will be able to regroup as they wish. If, somehow, the producers regain their nerve, they can more or less do as they wish. They will have an initial difficulty in overcoming the globalists’ death throes, but in endurance they will reclaim their world. A Second American Revolution The last time a broad group of producers asserted their will and stuck to it was the American Revolution. Contrary to any conventional wisdom of the time, they defeated the mightiest empire on the planet and changed the world. The American Revolution, as I have explained elsewhere, is misunderstood and used badly for propaganda purposes, but it was a unique and potent event. Producers have, at other times, pushed rulers to reform, but very seldom have they gathered the courage to say, “get lost, we’re doing it our way.” In order to achieve this goal the early Americans required separation, Christianity and the philosophy of John Locke. There are wonderful Lockean thinkers and teachers in the West today, but they are usually drowned out by the 24/7 clamor of 500 entertainment channels, music in nearly all public places and the recent Blackberry, texting and iPod fetishes. Withdrawal from the Circus The one real hope for the Lockeans is withdrawal from the great Western circus of mainstream TV, movies and music. In a previous article, I wrote that free news may begin vanishing, and that if it does, people will begin to choose more carefully. The thing I didn’t mention, however, was that this is occurring already. And the people who have been wandering away from the circus are mainly the producers. The first among the Lockeans are headed slowly away from the big noise. These people will begin to reclaim the right to their own opinions, even regarding how they choose to be ruled (or not). If this grows, there will be many people who don’t believe that they need to be coordinated and ordered by central elites and that Adam Smith was right: If you leave people alone, most of them will provide things needed by others, as if guided by an invisible, benevolent hand. In order to avoid this, the globalists will have to preserve media above all. Whether this includes subsidies for cable TV, free Internet services, or whatever, it will be strongly in their interests to provide them. If the circus ends, the young will start to ask impertinent questions. Lockean organization is effective, but it isn’t loud and flashy. Globalist organization is parasitic, but it comes with engaging stories and entertainments. If the circus reigns, the producers stand to be overwhelmed… yet again. The Exercise of Will I leave you with two quotes to consider, and I hope that you do so: The will of men is not shattered, but softened, bent, and guided. Men are seldom forced by it to act, but they are constantly restrained from acting. Such a power does not destroy, but it prevents existence. It does not tyrannize, but it compresses, enervates, extinguishes, and stupefies a people, until each nation is reduced to be nothing better than a flock of timid and industrious animals, of which the government is the shepherd. — Alexis de Tocqueville Mankind is made great or little by its own will. — Friedrich Schiller Paul Rosenberg FreemansPerspective.com
By Nick Giambruno Editor’s note: Today we have an urgent essay to share with you from Crisis Investing editor Nick Giambruno. You see, right now, a dangerous shift is playing out in Europe… one that could change the continent’s political landscape in a way not seen since before World War II. As Nick explains below, it all has to do with tomorrow’s important vote. Read on to get the details on how it will all go down—and what it could mean for you and your fellow Americans… Tomorrow, a vote in the Netherlands could push the euro and the EU one step closer to death… For the last several months, I’ve been warning readers about a populist tsunami washing through Europe. It’s drastically changing the continent’s political landscape in a way not seen since before World War II. This wave is flushing away traditional “mainstream” parties. And it’s bringing in anti-establishment populists who want to leave the euro currency and the European Union. It’s already hit the UK in the form of Brexit, killing David Cameron’s pro-EU government in the process. Then it struck Italy, washing away pro-EU Matteo Renzi’s government. After spending a few weeks in Italy last year, months in advance, I predicted the country’s constitutional referendum would fail and Renzi would resign. (I’m also an Italian citizen.) That’s why I advised Crisis Investing subscribers to short the euro with an investment that trades like any ordinary U.S. stock. As of writing, we’re sitting on a double-digit gain, but I expect there’s a lot more upside in the months ahead. Tomorrow, on March 15, the populist wave is set to hit the Netherlands. That’s when Dutch voters go to the polls. The anti-EU populist Party for Freedom is expected to win. It’s led by Geert Wilders, who was close to Trump’s campaign. Some even call him the “Dutch Trump.” Leaving the euro is a top priority for the Party for Freedom. If it wins, it would be another nail in the coffin for the European currency. Either way, the Dutch parliament will discuss how to leave the eurozone shortly after the March 15 election. A top lawmaker recently said that “the probe will examine whether it would be possible for the Dutch to withdraw from the single currency, and if so how,” Reuters reported. The euro’s problems are compounding and could get much worse, very soon. Germany (September 24) France (April 23) Why 2017 Could Offer a Rare “Second Chance” to Get Rich in the Stock Market Imagine waking up to find the size of your retirement account has doubled… all thanks to a small $500 investment. It sounds impossible… But this sort of thing has happened before. Could it happen again? Click here for the full story. These elections will ultimately determine the fate of the European Union. The Brexit vote, Donald Trump’s election, and the failure of Italy’s constitutional referendum have already boosted anti-euro populist parties in these countries. If the Party for Freedom wins in the Netherlands tomorrow, they’ll get another leg up. Populist parties have a real chance to win in both France and Germany. But even if they win in just one, the EU would likely unravel. The biggest issue in these elections is the migrant crisis, which we’ve covered here extensively. And the crisis is only accelerating. Every single migrant that arrives in Europe increases the chance that anti-EU populists will win a key election. That’s not good news for the EU or the euro. It’s also not good news for the U.S. Whatever happens in the EU—the world’s largest economy and a major U.S. trading partner—matters. If the euro collapses, expect it to trigger a stock market collapse in the U.S. The Financial Times recently put it this way: It would probably lead to the most violent economic shock in history, dwarfing the Lehman Brothers bankruptcy in 2008 and the 1929 Wall Street crash. And it could all begin unfolding tomorrow… Regards, — Two of Europe’s biggest countries have elections this year: Nick Giambruno Editor, Crisis Investing P.S. Tomorrow, March 15, is a crucially important date for Americans, too. Especially those who have any money in the stock market. Because on that day, the debt ceiling deadline hits. If Congress can’t come together to agree on a solution, the Treasury could run out of money. In the worst case, this could affect Social Security and government pension funding. Also, the last time the debt ceiling battle got fierce, the U.S. credit rating was downgraded. If that happens again, there could be big trouble in the markets. On top of the debt ceiling deadline, the Federal Open Market Committee (FOMC) will meet tomorrow—and all signs are pointing to a rise in interest rates. A steep series of rate increases could also spell doom for the market. That’s why Casey Research founder Doug Casey and I put together this urgent video designed to help you navigate markets in crisis… You can watch it here. How Doug turned every $1,000 into $86,000 An unusual group of companies I call “penny fuel stocks” are on the verge of a historic boom. Only TWICE in history has a similar event happened… and each time, these tiny stocks roared for 10-, 100-, some even saw rare but life-altering 1,000-fold returns. We know this because our research firm’s founder, Doug Casey, saw these returns himself. In fact, he saw a life-altering 86-fold return! These types of life-altering gains are something most investors never have the opportunity to see but now, thanks to the Trump administration, this same energy event is happening right now. And Doug and his team are now recommending plays with similar life-changing potential! Click here for full details. – Recommended Links
Technology Register Now » –shares Next Article Attend this free webinar and learn how you can maximize efficiency while getting the most critical things done right. Q: What security initiatives will have the biggest impact on my business?A: I often speak with individuals and management teams about the pros and cons of particular security initiatives. Those responsible for security today are often inundated with information on the topic. They see all the hype around the products, read the headlines of rising concerns and hear plenty of predictions about what is next. It’s not hard to see why some just want to know what to do now and what will have the biggest impact.Most companies I’ve spoken with have identified and implemented many of the common technologies important to any security program. They have a firewall, antivirus software, intrusion detection/protection, authentication technologies and so on. However, what continues to concern me is that these systems often go untested and unmanaged and therefore create a false sense of security.So while some companies would benefit from knowing what security devices to implement, for many, the most valuable recommendations are regarding procedures. In many circumstances, companies still fail to realize that a security program is just the beginning. All too often, monitoring and assessment responsibilities are either overlooked, underfunded or just not done properly.Security Audits Security audits are one of the best ways to identify security risks and validate the protection devices already put into place. Additionally, they’re an invaluable resource for justifying security budgets. However, many companies today fail to perform regular comprehensive audits of their internal and/or external IT infrastructure. And those that do perform audits often just test the externally exposed devices or only have high-level audits performed to ensure the above mentioned “common technologies” are being utilized. Comprehensive audits, however, should thoroughly test for all known vulnerabilities of all systems, correlate the findings, test exploits, identify the true level of risk to the business and detail remediation requirements. Audits properly performed with all these procedures by a reputable firm are in fact one of the most important initiatives you can undertake today.One of the reasons why security audits top my list is that they lay the groundwork for identifying what is needed to secure the IT infrastructure. In addition, they provide objective insight on the effectiveness of your overall security program. Such audits should be performed at least once per year against the internal environment and every six to 12 months against the external environment. This frequency is a suggested minimum, and many companies rightfully prefer to test certain aspects of a full audit more frequently.Managing Security One of most common and major security flaws I come across is that companies don’t properly monitor their security protection devices: the firewall, intrusion detection/protection, antivirus, operating system logs and the like. Security management doesn’t simply mean performing maintenance and administration; it involves consistent monitoring and the evaluation of events that happen on a daily basis. Yes, these tasks are mundane and generally resource-intensive. During a time when network/security administrators are already busy with other tasks, these activities are often overlooked. However, if this data were being monitored and if security events were being properly evaluated and acted upon, the vast majority of hacking-related events could be prevented.In most cases, with proper monitoring and reaction, businesses would not have to endure forced system outages, data loss or theft, virus outbreaks, Web site defacement or even the negative publicity that accompanies these and other such events. It’s not an easy or inexpensive task if performed internally. However, recent advances in security management software have reduced the security personnel requirements to perform these responsibilities. In addition, several reputable Managed Security Service Providers (MSSPs) have emerged with service offerings to outsource these tedious tasks. Outsourcing security monitoring and response can be a highly cost-effective method of dealing with this problem. It’s predicted that the vast majority of companies will be outsourcing this area of security in the next few years.Security Policies Another commonly overlooked item is your security policy. Every company should have some form of an information security policy in place and provided to every employee. Security policies provide a roadmap for both IT and non-IT personnel on how the company expects them to conduct themselves with any matter that affects the security posture of the business. In many cases, the actions have an obvious impact, such as the disclosure of logon account information to unauthorized personnel. While some policies are clearly security-related, other policies may be less obvious in terms of their impact to security risks to non-IT employees.An important point to consider is that an information security policy reflects the company’s stance on security in general. If no security policy exists or very little effort has been made in this area, it can be considered a direct reflection on the overall security posture of the business as a whole. This in itself can increase the likelihood of a company becoming a target and/or a victim.Several excellent books on the topic of information security policies exist today, making it easy and cost-effective to set up a basic policy. In addition, there are plenty of security consulting firms that can assist with more detailed policies.Michael Bruck is the founding partner of BAI Security, an 8-year-old information security consulting firm. Bruck leads his security team with a successful 16-year background in IT management and senior engineering positions. He is also the developer and author of best practices that are becoming standards in the information security consulting business. He can be reached via www.baisecurity.net or by e-mail at firstname.lastname@example.org .The opinions expressed in this column are those of the author, not of Entrepreneur.com. All answers are intended to be general in nature, without regard to specific geographical areas or circumstances, and should only be relied upon after consulting an appropriate expert, such as an attorney or accountant. The Key to Information Security Success Free Webinar | Sept 5: Tips and Tools for Making Progress Toward Important Goals September 8, 2003 To successfully secure your systems, focus on the procedures, not the technologies. 5 min read Opinions expressed by Entrepreneur contributors are their own. Add to Queue
Connex Digital Marketingsales conversionSales Funnelsales revenue Previous ArticleMarTech Interview with Van Diamandakis, CMO, PersadoNext Article10 Tips for a More Successful Price Optimization Project A Sales Funnel And Why Your Business Needs It Anna KucirkovaApril 23, 2019, 4:00 pmApril 17, 2019 That sales funnel of yours may be one among the key roots of your brand-new internet marketing policy for this age. Returning its fundamentals won’t only provide you with the best tool yet will additionally be in a position to preserve you valuable resources, that in turn, you may attach to your property to grow your online business. When you utilize the sales-funnel approach, you will be in a good position to appreciate distinguished sales conversion.What Is a Sales Funnel?Sales-Funnel Marketing is an approach in which a business draws new clients and prospects and leads them along a particular pre-destined route the business proprietors had in mind for them.The sales-funnel approach is mostly used to get fresh clients by offering freebies rather than attempting to convert them into consumers and buyers. In different cases, the sales funnel comprises getting buyers to buy more valuable items with time.How does a Sales Funnel Work?A sales funnel works like this: You offer an entry-level product, perhaps something for less than $20 (or even a free product) to allow the customer to ‘try you out’. When they buy the underlying item, and experience working with you, then you experiment with your item and see that it does all that you promised and that’s only the tip of the iceberg. At that point they will feel considerably more happy obtaining something else from you. What’s more, that something else can be a greater, higher valued item.The more someone has acquired from you, the more likely they are to buy from you in the future. So, instead of creating a $100 product up front, you will enjoy more long-term profit by utilizing a sales funnel.Read More: Making Voice Tech More Human Is as Easy as 1-2-3Why Do You Need a Sales Funnel?Improve Sales RevenueSuppose you got a report, which retails for $17. You may trade it 300 times, hence you would make $5,100 in transactions. Anyway, do you believe some would additionally purchase a similar item for $37 or still $197? I trust some would do it! Therefore, it’s absurd not to own a sales funnel fixed up for your digital business. It’s not important to worry with all the functional pages from the initial starting point, but, in any case, seek to have them.Improve Conversion RateWhile people move via their funnel, the number of them will lessen at the very time, and this is extra crucial, the common population which prevails in the funnel will presumably be more prepared to compensate for their extra expensive similar products. Accordingly, unselected people will be separated in the sales funnel. Additionally, those who remain will purchase more, and this will improve their conversions! Concentrate your efforts on those individuals and provide them with what they require, and they will likewise sell high-cost items.Assist in Predicting Sales VolumeOnline marketing is fun. Also, with every marketing side, you can determine the number of possible customers and later take the information to foretell the level of individual who will purchase your items. For instance, assume Paul traces your website’s traffic for say 10-weeks and discovers that he gets 10,000 guests to his site every month. 40/100 of them accept the free proposal (4000 sponsors) and 5% will purchase one or considerably extra products. After a few weeks, Paul will have statistics point-by-point concerning the number of individuals who purchase and plan in the funnel. Additionally, using those numbers, Paul can prognosticate the amount of money he can make with his sales funnel.Read More: How Managed Execution Services Help Marketers Yield Better ResultsIdentify Unsold Products/ServicesWith the numbers Paul gets each month, he can recognize services or products that don’t actually sell well. Therefore, you can execute modifications to your design and products to promote it, or you can even eliminate or replace existing items. That’s the idea why it’s normally important to keep a record of everything you perform in your funnel.ConclusionTowards the end of the day, your goal is to change sales into qualified leads. This model helps you through the sales process and shows you how to legitimately manage potential customers. The sales funnel gives you a course and focuses on the opportunities you need to deal with that will ultimately, help you save time, money and increase your bottom line. This is going into the design of your general sales strategy.Read More: What is Presentation Management and Why Do You Need It?
This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription. State Highlights: Colo. County May Sue Over No Change To Insurance Ratings A selection of health policy stories from Colorado, Oregon, Iowa, Connecticut, Minnesota and California.Health News Colorado: Garfield County May Sue, Accuses State Of Rubberstamping Insurance Lobbyists’ PlanEnraged that Colorado officials are refusing to change health insurance rating systems for this year or next, Garfield County’s attorney and commissioners are considering suing the state. “They’re violating the law,” said Garfield County Attorney Frank Hutfless. He said the state is discriminating against Garfield County by placing it with the highest-cost resort areas and therefore making it too difficult for people to afford health insurance, which was the primary purpose of the Affordable Care Act (McCrimmon, 2/4).The Associated Press: Fewer ER Visits For Ore. Medicaid PatientsPeople on the Oregon Health Plan are making fewer visits to the emergency room and more visits to primary care clinics, according to a new report on Oregon’s year-old coordinated care organizations. The Oregon Health Authority says the report shows Gov. John Kitzhaber’s overhaul of the state Medicaid program is achieving its goals in reducing unnecessary use of the emergency room (Cooper, 2/4).The Associated Press: Iowa Universities Refuse To Pay Health SubsidiesA nonprofit that subsidizes insurance policies for Iowans with health risks is suing the state’s three public universities, claiming they are refusing to pay millions in legally required fees. The Iowa Individual Health Benefit Reinsurance Association says the universities’ nonpayment could lead to higher assessments for other government agencies that are members and higher costs for patients (Foley, 2/4).Kaiser Health News: A Third Generation Doctor Questions The ProfessionBeing a doctor in America is changing, in part because of the Affordable Care Act and also because of longer trends in the practice of medicine. Drs. Robert and Michael Sawyer practice at Denver Health, the city’s big public hospital downtown. Sawyers have worked or taught here as physicians since the 1930s, so they have a unique perspective on how today’s challenges stack up against those that physicians have faced in the past (Whitney, 2/5).The CT Mirror: Leonardi Cool On Federal Regulation Of Insurance IndustryConnecticut’s insurance commissioner told members of Congress Tuesday he has serious reservations about extending federal oversight of the insurance industry. Thomas Leonardi, commissioner of Connecticut’s Insurance Department, was invited by a Republican member of the House Financial Services Committee to weigh in on new federal oversight of the insurance industry, which is largely regulated by the states. At issue is the new Federal Insurance Office that was created by the Dodd-Frank financial reform bill and tasked to report on weaknesses in the insurance industry (Radelat, 2/4).Minnesota Public Radio: Patients Need An Affordable, Stable Home To Be HealthyHealth care companies are increasingly focused on patients like (Vanessa) Smith, whose housing difficulties can compromise their health. Indeed, a growing body of research indicates a strong link between health and housing. If patients’ rent is too high, they might avoid spending money on medications to treat diabetes and other diseases. Frequent moves also can lead to or deepen mental health problems (Baxter, 2/4).The California Health Report: A Dozen California Hospitals Among Most Expensive In U.S.When a doctor sees a patient at Olympia Hospital in Los Angeles for a routine, 15-minute consultation, the hospital typically bills Medicare about $1,100 for the service. Two miles away, Cedars-Sinai Medical Center bills the government just under $200 for the same kind of visit. Medicare sets its own rates, so the program ultimately pays both hospitals the same amount, or nearly so, regardless of how much they try to charge. But the huge disparity in billing for the same procedure in the same city raises questions about how hospitals establish their rates, who pays them, and what connection, if any, the charges have to the actual cost of providing care. The mysterious billing practices are fueling a nationwide drive for more transparency (Richard, 2/5).Salem, Ore., Statesman Journal: Oregon Health Plan Reforms Preventing Costly Hospital Care, Report ShowsOregon’s new program that is changing how its Medicaid patients are being treated received another positive review in the quarterly report released today. According to the Oregon’s Health System Transformation report, which covers the first nine months of coordinated care organizations’ performance in 2013, emergency visits and spending are down, primary care visits and spending are up and hospital readmissions are down (Yoo, 2/4).
Reviewed by James Ives, M.Psych. (Editor)Oct 8 2018Data from a clinical trial has shown that how people respond to treatment for Bipolar Disorder may be influenced by their weight and the overall quality of their diet, including whether they are eating a diet high in foods thought to contribute to general inflammation. These are early results, but if replicated may mean that treatment of some mental health problems could benefit from the inclusion of dietary advice. This is presented at the ECNP Conference in Barcelona.Bipolar Disorder (which used to be called ‘manic depression’) is characterised by episodes of mood swings, between being very up or very down with periods in between the two extremes. The fact that there are two opposite sets of symptoms means that finding an effective treatment is difficult. While current medications are useful, they are better at targeting mania symptoms (the ‘up’ phase), leaving a lack of effective treatment for people experiencing depressive episodes. Now a group of Australian, German and American scientists have shown those who have a high quality diet, a less inflammatory diet, and/or a low BMI (Body Mass Index) may respond better to an add-on nutraceutical treatment provided as part of a clinical trial.”If we can confirm these results, then it’s good news for people with Bipolar Disorder, as there is a great need for better treatments for the depressive phase of Bipolar Disorder” said lead researcher Melanie Ashton of Deakin University in Australia.A total of 133 participants were randomly assigned to take a combination of nutraceuticals (compounds derived from foods such as vitamins or minerals that treat or prevent a disease or disorder) including the anti-inflammatory amino acid n-acetylcysteine (NAC), or NAC alone, or a placebo (a dummy pill) for 16 weeks. Participants received the study medication in addition to any stable treatments they were already receiving. Researchers measured BMI at the beginning of the study, and then measured depression and how a person is able to function in their day to day life. Researchers also rated whether a participant was improving and, if so, how much, over the next 20 weeks. Participants filled in a questionnaire about what they usually eat over the year and researchers calculated a diet quality score, where good diets included a healthy diet with lots of fruit and vegetables, whereas poorer-quality diets had more saturated fat, refined carbohydrates and alcohol. These types of diets were then categorised as either anti-inflammatory or pro-inflammatory based on foods that affect inflammation.Related StoriesDiet and physical exercise do not reduce risk of gestational diabetesHigh-fat, low-carbohydrate diet may improve brain function and memory in older adultsHigh salt intake inhibits tumor growth in mice, shows studyMelanie Ashton continued, “We found that people who had a better-quality diet, a diet with anti-inflammatory properties, or a lower BMI, showed better response to add-on nutraceutical treatment than did those who reported a low-quality diet, or a diet including foods that promote inflammation, or who were overweight.What this means, if these results can be repeated in a larger trial, is that treatment for Bipolar Disorder would need to take into account what a person eats and their weight.There are some points we need to note about this study. This is a randomised, controlled trial, but what we found were exploratory outcomes; in other words, it wasn’t the main result that we were testing. Our result is statistically significant, but because the study wasn’t specifically designed to test the effect of diet quality,inflammatory diets and BMI on drug response in general, it is necessary to see the work replicated in a larger study before any firm conclusions can be formed”.Commenting, Professor Eduard Vieta (Barcelona) said:”This is interesting work, which holds out the possibility that patients with Bipolar Disorder may benefit from a balanced diet. However, it is an early study, and we need more research before we can think whether this might affect clinical practice”.Professor Vieta was not involved in this work, it is an independent comment. Source:https://www.ecnp.eu/
Source:https://www.psychologicalscience.org/news/releases/happy-spouses-longer-lives.html Reviewed by James Ives, M.Psych. (Editor)Apr 24 2019Research suggests that having a happy spouse leads to a longer marriage, and now study results show that it’s associated with a longer life, too. The study was published in Psychological Science, a journal of the Association for Psychological Science.”The data show that spousal life satisfaction was associated with mortality, regardless of individuals’ socioeconomic and demographic characteristics, or their physical health status,” says study author Olga Stavrova, a researcher at Tilburg University in the Netherlands.Notably, spouses’ life satisfaction was an even better predictor of participants’ mortality than participants’ own life satisfaction. Participants who had a happy partner at the beginning of the study were less likely to pass away over the next 8 years compared with participants who had less happy partners.”The findings underscore the role of individuals’ immediate social environment in their health outcomes. Most importantly, it has the potential to extend our understanding of what makes up individuals’ ‘social environment’ by including the personality and well-being of individuals’ close ones,” says Stavrova.Life satisfaction is known to be associated with behaviors that can affect health, including diet and exercise, and people who have a happy, active spouse, for example, are likely to have an active lifestyle themselves. The opposite is also likely to be true, says Stavrova:”If your partner is depressed and wants to spend the evening eating chips in front of the TV — that’s how your evening will probably end up looking, as well.”Stavrova examined data from a nationally representative survey of about 4,400 couples in the United States who were over the age of 50. The survey, funded by the National Institute on Aging, collected data on participants who had spouses or live-in partners; 99% of the sampled couples were heterosexual.For up to 8 years, participants and their spouses reported on life satisfaction and various factors hypothesized to be related to mortality, including perceived partner support and frequency of physical activity. They also completed a self-rated health measure and provided information related to their morbidity (as measured by number of doctor-diagnosed chronic conditions), gender, age at the beginning of the study, ethnicity, education, household income, and partner mortality. Participant deaths over the course of the study were tracked using the National Death Index from the Centers for Disease Control and Prevention or spouses’ reports.Related StoriesBridging the Gaps to Advance Research in the Cannabis IndustryHigher levels of physical activity not linked to greater volume or activity of brown adipose tissueTAU’s new Translational Medical Research Center acquires MILabs’ VECTor PET/SPECT/CTAt the end of 8 years, about 16% of participants had died. Those who died tended to be older, male, less educated, less wealthy, less physically active, and in poorer health than those who were still alive; those who died also tended to report lower relationship satisfaction, lower life satisfaction, and having a partner who also reported lower life satisfaction. The spouses of participants who died were also more likely to pass away within the 8-year observation period than were spouses of participants who were still living.The findings suggest that greater partner life satisfaction at the beginning of the study was associated with lower participant mortality risk. Specifically, the risk of mortality for participants with a happy spouse increased more slowly than mortality risk for participants with an unhappy spouse. The association between partner life satisfaction and mortality risk held even after accounting for major sociodemographic variables, self-rated health and morbidity, and partner mortality.Exploring plausible explanations for these findings, Stavrova found that perceived partner support was not related to lower participant mortality. However, higher partner life satisfaction was related to more partner physical activity, which corresponded to higher participant physical activity, and lower participant mortality.This research demonstrates that partner life satisfaction may have important consequences for health and longevity. Although the participants in this study were American, Stavrova believes the results are likely to apply to couples outside of the United States, as well.”This research might have implications for questions such as what attributes we should pay attention to when selecting our spouse or partner and whether healthy lifestyle recommendations should target couples (or households) rather than individuals,” says Stavrova.Future research could also investigate larger social networks to see if the same pattern of results emerges in the context of other relationships.
Major progress has been achieved in diagnosis and treatment in recent years, and there will be more, but the number of people with sickle cell disease is growing in poor countries. It’s important above all to focus on Africa and Asia, as well as Brazil, where funding of the public health system is not just not increasing but appears to be falling, so that all this progress is endangered in Brazil.”Fernando Ferreira Costa, a full professor and researcher at the Hematology and Hemotherapy Center (Blood Center) of the University of Campinas (UNICAMP) in São Paulo State, Brazil Costa, the only Brazilian among the authors of the study, was referring to the existence of publicly funded blood centers and support from SUS, the national health service, for PNTN, a nationwide neonatal screening program, which administers, among other diagnostic modalities, the heel prick test, which is designed to detect hemoglobinopathies and six other diseases in newborns. Costa also stressed the importance of the free supply by the SUS of hydroxycarbamide (also known as hydroxyurea), the main drug used to treat sickle cell anemia, and the blood transfusions required by many patients.”A lot of progress has been made in Brazil, which has successfully established centers of excellence. Diagnosis, treatment and research have all developed significantly in recent decades,” he told.Costa is the principal investigator for the Thematic Project “Red blood cell disorders: pathophysiology and new therapeutic approaches” funded by Paulo Research Foundation – FAPESP.The Nature Reviews article highlights a decision by the US Food and Drug Administration (FDA) to rate the development of new treatments for sickle cell disease (SCD) as a top priority, facilitating investment by the pharmaceutical industry. As a result, many drugs targeting one or more of the mechanisms that contribute to SCD are currently being tested in humans.”The prospects for new treatments for SCD have never looked better,” the authors conclude.Hereditary mutationSickle cell anemia is the most severe and prevalent form of SCD. Sickle-shaped red blood cells are deformed and become rigid, with a tendency to polymerize – form groups that stick to the inner lining of blood vessels (endothelium) – impairing or even blocking the flow of blood.In addition to causing unpredictable pain episodes, blood vessel blockage greatly increases the risk of heart attack, stroke, chronic kidney disease and pulmonary embolism, among other complications. “It’s a chronic disease requiring medications and control for life,” Costa said.Hydroxycarbamide is the medication currently used to prevent this type of blockage (vaso-occlusion). The drug boosts the production of a protein called fetal hemoglobin, which hinders the polymerization of defective hemoglobin and mitigates the risk of vaso-occlusion.In recent years, researchers at UNICAMP’s Blood Center have discovered other uses for the drug, such as preventing some of the complications that result from hemolysis, the rupture of red blood cells and the release of hemoglobin into the blood stream, which potentially leads to chronic inflammation.The only treatment capable of curing sickle cell anemia, however, is a bone marrow transplant. In Brazil, the procedure has been covered by the SUS only since 2015. Many bone marrow transplants in patients with sickle cell anemia in Brazil, always involving compatible siblings, have been performed by the Center for Cell-Based Therapy (CTC), hosted by the University of São Paulo’s Ribeirão Preto Medical School (FMRP-USP). The CTC is a Research, Innovation and Dissemination Center (RIDC) funded by FAPESP.Related StoriesOlympus Europe and Cytosurge join hands to accelerate drug development, single cell researchNANOLIVE‘s novel CX-A defines a new standard for live cell imaging in 96 well plates for continuous organelle monitoring in cell populationsAbcam Acquire Off-The-Shelf Diploid Library of Over 2,800 Knockout Cell LinesThe article notes that gene therapy has been considered promising as a treatment for SCD since the mid-1990s, but clinical trials have only recently begun, seeking FDA approval for a procedure using lentiviral vectors, which involves inserting genes engineered to reduce sickling into hematopoietic stem cells. The initial results have been promising.Other approaches, such as CRISPR/Cas9 gene editing, which can replace a specific DNA region, are also considered promising for the treatment of SCD. This technique is currently used only in mice and cultured human cells.Many ethical issues must be resolved before such techniques can be used in humans, the authors write: “Long-term follow-up trials will be needed to confirm their safety and sustainability, and the accessibility of gene therapy in high-burden, low-income areas needs to be addressed”.As noted by the article, the burden of SCD is heavier on poor countries. In high- and middle-income countries, the clinical course of SCD has substantially changed since the 1970s in both children and adults. The survival of children with sickle cell anemia is similar to that of healthy children in the United States and the United Kingdom. In Africa, however, mortality rates range from 50% to 90% for children under 5 years of age with the disease. Adults with SCD in high-income countries can now expect to live well into their sixties.Inequality of SCD distribution and careThe Brazilian Health Ministry estimates that between 30,000 and 50,000 people have some form of SCD in the country. Worldwide, 300,000-400,000 babies are estimated to be born with one of the genetic mutations each year, with 230,000 in sub-Saharan Africa alone.Thanks partly to the PNTN national newborn screening program, Brazil has reliable epidemiological data and can take action before the symptoms of SCD appear. The heel prick test was officially implemented by the federal government in 2001, although it had already been in use for some time in certain parts of the country.In fact, coverage is still highly unequal. In 2016, all hospitals in the state of Minas Gerais performed the heel prick test, while only approximately half did so in the state of Amapá, according to Costa.Screening has enabled the authorities to estimate survival rates and the main causes of death among people with SCD. It is also the basis for the provision of prophylaxis, especially vaccination and the administration of penicillin before age 5 to avoid infections, which are the main cause of death.Ensuring universal coverage is key because the distribution of SCD is so uneven. Sickle cell anemia is more common in the North and Northeast than in other regions of Brazil because the mutation that causes the disease is more prevalent among people of African ancestry, of whom there are many in those regions.On the other hand, thalassemia, especially the most severe form, is more common among people of Mediterranean ancestry, such as the many descendants of Italian immigrants in the South and Southeast regions.The article shows that in areas without screening programs for newborns, the initial diagnosis of SCD occurs at approximately 21 months of age. For many individuals, the first sign of sickle cell anemia is a fatal infection or an acute splenic sequestration crisis, when sickled red blood cells become trapped in the spleen in large numbers, causing a sudden enlargement of the organ that can be life-threatening. Early diagnosis and penicillin prophylaxis reduces mortality in the first five years from 25% to less than 3%, according to the article.The problem is that accurate estimates of the number of sickle cell anemia patients are difficult to obtain, even with good healthcare systems and in countries with universal screening programs such as Brazil. Fortunately, the collection of epidemiological data is steadily improving. Geospatial and other sophisticated methods could produce fairly reliable estimates of the number of people with sickle cell anemia worldwide.These projects depend on large collaborative networks for data collection and processing, and the ability to analyze big data, all of which requires substantial amounts of funding.”Frédéric B. Piel, a researcher at Imperial College London and one of the authors of the article Reviewed by James Ives, M.Psych. (Editor)Jun 13 2019The promise of new treatments for sickle cell disease, a group of inherited red blood cell disorders, has never been so great, but it will only be realized if there is constant investment in health policies such as programs for screening newborns, especially in sub-Saharan Africa, where most cases occur.This point is made in a comprehensive review of the main research findings regarding sickle disease published in Nature Reviews Disease Primers and signed by experts affiliated with institutions in the United States, United Kingdom, Ghana and Brazil.Sickle cell disease is caused by a mutation in the gene that helps make hemoglobin, the oxygen transport protein in red blood cells. Red blood cells containing normal hemoglobin are disc-shaped, but cells with this mutation are sickle-shaped. Sickle cell anemia is the most severe disorder in the group of related diseases. Another medically important hemoglobin-related disorder is thalassemia, a hereditary form of chronic anemia with different degrees of severity. Source:Fundação de Amparo à Pesquisa do Estado de São PauloJournal reference:Vichinsky, E.P. et al. (2018) Sickle cell disease. Nature Reviews Disease Primers. doi.org/10.1038/nrdp.2018.10.
Reviewed by James Ives, M.Psych. (Editor)Jun 25 2019A checkpoint may delay travelers but it can help give cancer free rein by suppressing the natural immune response that should destroy it, researchers say.Now they want to learn more about how the enzyme CD73 — an abundant checkpoint in our body that helps keep our immune system from getting out of control — is helping often-aggressive head and neck cancers thrive.CD73 is found in all cells and in abundance in the supportive microenvironment of head and neck cancers. High levels already are associated with poor prognosis in the most common type of these cancers.Immunologist Dr. Yan Cui and colleagues otolaryngologists Drs. Michael Groves and J. Kenneth Byrd want to know more about where high levels originate with the long-term goal of blocking them.One way CD73 appears to support cancer is by converting the cell fuel ATP, or adenosine triphosphate, which typically works to activate the immune response, back to adenosine, a natural compound that inhibits it, says Cui, a member of the Cancer Immunology, Inflammation and Tolerance Research Program at the Georgia Cancer Center and professor in the Department of Biochemistry and Molecular Biology at the Medical College of Georgia at Augusta University.That key action makes CD73 an immune checkpoint and potential treatment target in the most common head and neck cancers, called squamous cell carcinomas, the researchers say.Cui is principal investigator on a $420,000, two-year Exploratory/Developmental Research Grant from the National Institute of Dental and Craniofacial Research that is providing more insight into how CD73 supports cancer.Most of the help seems to come from the environment the tumor has built to support itself, called the tumor microenvironment. Cui has shown that in the microenvironment, stromal cells like fibroblasts, express high levels of CD73, which helps create a perfect storm that ultimately helps cancer cells survive. These cancer-associated fibroblasts seem to be particularly adept at making CD73 and Cui has found high levels of fibroblasts can mean low levels of T cells, key drivers of the immune response. In fact, Cui has seen in some head and neck cancers a large number of immune cells clearly present and clearly not functioning. “They are there, but they are tolerant,” Cui says, while in other tumors, immune cells are just MIA.”CD73 very rapidly gets rid of the ATP and changes it to the immunosuppressive adenosine,” says Cui of the powerful immune checkpoint. “Adenosine, in turn, can inhibit T cell function; in very high concentrations it can even kill the T cells,” she says.Cui and physicians in the MCG Department of Otolaryngology who treat these patients, hope their studies of fresh surgical specimens will turn around that scenario so that CD73 production by stromal cells is reduced and T cells can regain their focus. Their focus, squamous cell cancers, comprise about 90 percent of head and neck cancers and occur on the mucosal surfaces inside our head and neck, like the lining of the mouth, nose and throat, according to the National Cancer Institute. They are generally categorized by where they start, like in the oral cavity, which includes the lip, tongue, gums and pretty much most of what we can see when we open our mouths wide.The often-aggressive cancers affect about 60,000 people annually with human papillomavirus, the most common sexually transmitted infection in the nation, having now surpassed smoking and drinking as a cause of these cancers today.The cancers are particularly tough to treat when they have spread locally or regionally, Cui says, with survival rates of less than 50 percent. Metastasis, to even a single lymph node, moves the cancer from early to advanced stage and can cut your survival rate in half, says Groves, MCG otolaryngologist and a co-investigator on the new study.People may come to see Groves after a few weeks of hoarseness and he discovers one small, comparatively treatable tumor on the vocal cords. Patients also come with a massive neck tumor and trouble breathing by the time they get to the emergency room. “This is a very heterogeneous group,” Groves notes.Related StoriesNew study to ease plight of patients with advanced cancerStudy reveals link between inflammatory diet and colorectal cancer riskBacteria in the birth canal linked to lower risk of ovarian cancerTo get a better idea of what different cell populations are doing, they are looking at the interaction and distribution of stromal cells and immune cells in recently removed human cancer specimens. They are measuring CD73 expression by the different stromal cell types and looking at how CD73 is modifying the immune response, in this case to benefit the tumor. They are looking at the function and gene expression of individual cells.”It’s important to know these types of interactions so you can identify targets,” Groves says.”Everything in our body is a balance,” Cui notes, and indefinitely blocking CD73 could definitely have bad consequences like enabling autoimmune disease by enabling the immune system, rather than the cancer, to go unchecked. But the researchers think temporarily blocking CD73 may help improve treatment response and survival for some of these patients and the current study should provide more evidence of whether that’s true.There already are some small molecules that can suppress CD73 function used in the lab by researchers like Cui, and some of the inhibitors are being used in early phase clinical trials for other tumor types, she says, but results are not yet known.Checkpoint inhibitors are an emerging type of immunotherapy that block proteins that can block the immune response to cancer. More established targets include proteins like PD-1 and CTLA-4, which can be produced by both immune cells and cancer cells. Like CD73, some cancer cells have a lot these proteins. But so far at least, existing checkpoint inhibitors have not been very successful in treating head and neck cancers specifically, the researchers say, and generally speaking are used for palliative care when a cancer returns after more standard therapies, says Groves.Standard treatment for head and neck cancer can include surgery, chemotherapy and radiation, and can mean patients lose their ability to chew, swallow or speak, says Dr. Calvin Myint, fourth-year resident in the MCG Department of Otolaryngology and a member of the research team.Acknowledging the genetic heterogeneity of even the same tumor type in the same location and stage in two different people, the researchers hope another thing these and other studies will do is enable physicians to determine as early as possible the aggressiveness of a patient’s tumor. That can help steer physicians away from more aggressive therapies — and their more aggressive side effects — when possible, Myint says.”You have to figure out what is best for that patient at the moment in time they present,” Groves says. For example, there is now evidence that a combination of chemotherapy and radiation therapy, versus surgery as well, is best for tonsil cancer that has spread to the lymph nodes because the destruction of tissue from surgery can be extensive and survival with chemotherapy and radiation is just as good, Groves says.Higher CD73 levels also have been associated with shorter survival from breast cancer and with more aggressive, migrating breast cancer cells. In a bit of a vicious cycle, tumor cells seems to be very good at producing CD73 and hypoxia, or low oxygen levels, and cell death that happen with cancer can produce more.The tumor microenvironment is basically the body resources like normal cells, including immune cells, blood vessels and molecules in the vicinity, cancer coops to support itself.It was previously thought that stromal cells inside the microenvironment just provided literal support to a tumor. “Now we understand they have much more function than just holding the tumor together. They have an immune regulatory function,” Cui says.Groves expects to see head and neck cancer rates continue to increase along with HPV infection rates until HPV vaccines begin to significantly impact spread of the virus.He always tells patients there are certain things that can’t be controlled like the genetic makeup of the tumor, the response of the tumor and the patient’s body to treatment and how advanced the disease was when the patient presented. Factors they can control include not delaying surgery or missing treatment appointments, and taking overall care of themselves like eating well, drinking plenty of water and getting plenty of rest. Groves is hoping the work of Cui and other basic scientists will help move some of the uncontrollable factors into the controllable category. Source:Medical College of Georgia at Augusta University If we better understand the process, we can design how to target those processes, interrupt those interactions to reverse suppression and enhance immune activity”Dr. Yan Cui