Participatory Budgeting: Could It Diminish Health Disparities in the United States?

Participatory budgeting (PB)—a democratic process where ordinary residents decide directly how to spend part of a public budget—has gained impressive momentum in US municipalities, spreading from one pilot project in Chicago’s 49th ward in 2009 to 50 active PB processes across 14 cities in 2016–2017. Over 93,600 US residents voted in a PB process in 2015–2016, deciding over a total of about $49.5 million and funding 264 projects intended to improve their communities. The vast majority of US PB processes take place in large urban centers (e.g., New York City, Chicago, Seattle, Boston), but PB has also recently spread to some smaller cities and towns [1]. Figure 1 illustrates the growth of PB processes in the USA, and within New York City and Chicago council districts specifically.

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Fig. 1 Participatory budgeting in the USA has grown from 1 process in 2009–2010 to 50 processes in 2016–2017

PB constitutes a rare form of public engagement in that it typically comprises several distinct stages that encourage residents to participate from project idea collection to project implementation (see Fig. 2). The decisive public vote in US PB is practically binding as elected officials commit to implementing the public decision at the outset of the process. Moreover, all current PB processes in the USA have expanded voting rights to residents under 18 years old and to non-citizens. Under President Obama, the White House recognized PB as a model for open governance. Participatory Budgeting Project, a nonprofit organization that advocates for PB, won the 2014 Brown Democracy Medal, which recognizes the best work being done to advance democracy in the USA and internationally.

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Fig. 2 Typical stages of a participatory budgeting process in the USA

PB has been lauded for its potential to energize local democracy, contribute to more equitable public spending and help reduce inequality [2, 3]. Social justice goals have been explicit in US PB from the start. Grassroots advocates, technical assistance providers, and many elected officials who have adopted it emphasize that PB must focus on engaging underrepresented and marginalized communities [2, 4, 5]. PB steering committees have specified equity and inclusiveness goals in PB rule books [6, 7]. The most conclusive research so far on PB’s potential to reduce social inequalities, however, comes from Brazil, where PB started in 1989. In Brazil, PB has been associated with a reduction in extreme poverty, better access to public services, greater spending on sanitation and health services, and, most notably, a reduction in child and infant mortality [8, 9].In this paper, we outline three mechanisms by which PB could affect health disparities in US municipalities: First, by strengthening residents’ psychological empowerment; second, by strengthening civic sector alliances; and third, by (re)distributing resources to areas of greatest need. We summarize the theoretical argument for these impacts, discuss the existent empirical evidence, and highlight promising avenues for further research.     

Urban HEART Detroit: a Tool To Better Understand and Address Health Equity Gaps in the City

The Urban Health Equity Assessment Response Tool (Urban HEART) combines statistical evidence and community knowledge to address urban health inequities. This paper describes the process of adopting and implementing this tool for Detroit, Michigan, the first city in the USA to use it. The six steps of Urban HEART were implemented by the Healthy Environments Partnership, a community-based participatory research partnership made up of community-based organizations, health service providers, and researchers based in academic institutions. Local indicators and benchmarks were identified and criteria established to prioritize a response plan. We examine how principles of CBPR influenced this process, including the development of a collaborative and equitable process that offered learning opportunities and capacity building among all partners. For the health equity matrix, 15 indicators were chosen within the Urban HEART five policy domains: physical environment and infrastructure, social and human development, economics, governance, and population health. Partners defined the criteria and ranked them for use in assessing and prioritizing health equity gaps. Subsequently, partners generated a series of potential actions for indicators prioritized in this process. Engagement of community partners contributed to benchmark selection and modification, and provided opportunities for dialog and co-learning throughout the process. Application of a CBPR approach provided a foundation for engagement of partners in the Urban HEART process of identifying health equity gaps. This approach offered multiple opportunities for discussion that shaped interpretation and development of strategies to address identified issues to achieve health equity.     

Near-fatal pediatric asthma managed with pumpless arteriovenous carbon dioxide removal

OBJECTIVE: To describe the use of pumpless arteriovenous carbon dioxide removal in support of four pediatric patients with near-fatal asthma. DESIGN: Report of four cases. SETTING: Tertiary care university pediatric intensive care unit. PATIENTS: Four pediatric patients, ages 4, 10, 12, and 13, were intubated and initially managed with positive pressure ventilation for severe respiratory failure. Despite pharmacologic therapy with inhaled beta-agonists, inhaled anticholinergics, systemic corticosteroids, and intravenous magnesium, marked progressive hypercapnia and acidosis rapidly developed requiring high levels of positive pressure ventilation. INTERVENTIONS: Application of pumpless arteriovenous carbon dioxide removal (AVCO2R) via percutaneous femoral cannulation. MEASUREMENT AND MAIN RESULTS: Arterial or mixed venous carbon dioxide partial pressure (PCO2) and pH were measured before and at intervals following initiation of AVCO2R. Before cannulation, PCO2 was elevated to 100, 108, 90, and 186 mm Hg in the four patients, with corresponding pH of 7.07, 6.96, 7.09, and 6.80, respectively. Pco2 levels were reduced to more acceptable levels (37-57 mm Hg) within 2-4 hrs of initiation of AVCO2R, with corresponding improvements in pH despite reductions in ventilatory frequency and tidal volumes to safe levels. Duration of support ranged from 18 hrs to 5 days during resolution of bronchospasm. No red blood cell or platelet transfusions were required, and no complications resulted from AVCO2R or from mechanical ventilation. All patients were discharged from the hospital without sequelae. CONCLUSIONS: Percutaneous cannulation with a simplified pumpless extracorporeal circuit is capable of removing sufficient carbon dioxide to allow application of a protective ventilatory strategy in severe hypercapnic pediatric respiratory failure. The procedure was safely applied without complications in four pediatric patients as young as 4 yrs of age.     

Pharmacological and pharmacokinetic properties of a structurally novel, potent, and selective metabotropic glutamate 2/3 receptor agonist: in vitro characterization of agonist (-)-(1R,4S,5S,6S)-4-amino-2-sulfonylbicyclo[3.1.0]-hexane-4,6-dicarboxylic acid (LY404039)

Group II metabotropic glutamate (mGlu) receptor agonists, including (1S,2S,5R,6S)-2-aminobicyclo[3.1.0]hexane-2,6-dicarboxylate monohydrate (LY354740) and (-)-2-oxa-4-aminobicyclo[3.1.0]hexane-4,6-dicarboxylate (LY379268), have demonstrated efficacy in animal models of anxiety and schizophrenia, and LY354740 decreased anxiety in human subjects. Herein, we report the in vitro pharmacological profile and pharmacokinetic properties of another potent, selective, and structurally novel mGlu2/3 receptor agonist, (-)-(1R,4S,5S,6S)-4-amino-2-sulfonylbicyclo[3.1.0]hexane-4,6-dicarboxylic acid (LY404039) and provide comparisons with LY354740. Similar to LY354740, LY404039 is a nanomolar potent agonist at recombinant human mGlu2 and mGlu3 receptors (K(i) = 149 and 92, respectively) and in rat neurons expressing native mGlu2/3 receptors (Ki = 88). LY404039 is highly selective for mGlu2/3 receptors, showing more than 100-fold selectivity for these receptors, versus ionotropic glutamate receptors, glutamate transporters, and other receptors targeted by known anxiolytic and antipsychotic medications. Functionally, LY404039 potently inhibited forskolin-stimulated cAMP formation in cells expressing human mGlu2 and mGlu3 receptors. Electrophysiological studies indicated that LY404039 suppressed electrically evoked excitatory activity in the striatum, and serotonin-induced l-glutamate release in the prefrontal cortex; effects reversed by LY341495. These characteristics suggest LY404039 modulates glutamatergic activity in limbic and forebrain areas relevant to psychiatric disorders; and that, similar to LY354740, it works through a mechanism that may be devoid of negative side effects associated with current antipsychotics and anxiolytics. Interestingly, despite the slightly lower potency (approximately 2-5-fold) of LY404039 versus LY354740 in binding, functional, and electrophysiological assays, LY404039 demonstrated higher plasma exposure and better oral bioavailability in pharmacokinetic experiments. Collectively, the current data indicate that LY404039 may be valuable in the treatment of neuropsychiatric disorders, including anxiety and psychosis.     

Identification and characterization of cholest-4-en-3-one, oxime (TRO19622), a novel drug candidate for amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder characterized by progressive death of cortical and spinal motor neurons, for which there is no effective treatment. Using a cell-based assay for compounds capable of preventing motor neuron cell death in vitro, a collection of approximately 40,000 low-molecular-weight compounds was screened to identify potential small-molecule therapeutics. We report the identification of cholest-4-en-3-one, oxime (TRO19622) as a potential drug candidate for the treatment of ALS. In vitro, TRO19622 promoted motor neuron survival in the absence of trophic support in a dose-dependent manner. In vivo, TRO19622 rescued motor neurons from axotomy-induced cell death in neonatal rats and promoted nerve regeneration following sciatic nerve crush in mice. In SOD1(G93A) transgenic mice, a model of familial ALS, TRO19622 treatment improved motor performance, delayed the onset of the clinical disease, and extended survival. TRO19622 bound directly to two components of the mitochondrial permeability transition pore: the voltage-dependent anion channel and the translocator protein 18 kDa (or peripheral benzodiazepine receptor), suggesting a potential mechanism for its neuroprotective activity. TRO19622 may have therapeutic potential for ALS and other motor neuron and neurodegenerative diseases.     

Studying sex and gender differences in pain and analgesia: a consensus report

In September 2006, members of the Sex, Gender and Pain Special Interest Group of the International Association for the Study of Pain met to discuss the following: (1) what is known about sex and gender differences in pain and analgesia; (2) what are the "best practice" guidelines for pain research with respect to sex and gender; and (3) what are the crucial questions to address in the near future? The resulting consensus presented herein includes input from basic science, clinical and psychosocial pain researchers, as well as from recognized experts in sexual differentiation and reproductive endocrinology. We intend this document to serve as a utilitarian and thought-provoking guide for future research on sex and gender differences in pain and analgesia, both for those currently working in this field as well as those still wondering, "Do I really need to study females?"     

Evaluating thin compression paddles for mammographically compatible ultrasound

We are developing a combined digital mammography/3D ultrasound system to improve detection and/or characterization of breast lesions. Ultrasound scanning through a mammographic paddle could significantly reduce signal level, degrade beam focusing and create reverberations. Thus, appropriate paddle choice is essential for accurate sonographic lesion detection and assessment with this system. In this study, we characterized ultrasound image quality through paddles of varying materials (lexan, polyurethane, TPX, mylar) and thicknesses (0.25 to 2.5 mm). Analytical experiments focused on lexan and TPX, which preliminary results demonstrated were most competitive. Spatial and contrast resolution, side-lobe and range lobe levels, contrast and signal strength were compared with no-paddle images. When the beamforming of the system was corrected to account for imaging through the paddle, the TPX 2.5 mm paddle performed the best. Test objects imaged through this paddle demonstrated < or = 15% reduction in spatial resolution, < or = 7.5 dB signal loss, < or = 3 dB contrast loss and range lobe levels > or = 35 dB below signal maximum over 4 cm. TPX paddles <2.5 mm could also be used with this system, depending on imaging goals. In 10 human subjects with cysts, small CNR losses were observed but were determined to be statistically insignificant. Radiologists concluded that 75% of cysts in through-paddle scans were at least as detectable as in their corresponding direct-contact scans.