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This essay involves a set of speculations concerning the role plant-granted visions play in the formation of the Shuar subject. It also reflects on the need for an ethnography of secrecy and the ineffable. In both these tasks I seek to engage psychoanalytic theory. Jacques Lacan’s distinction between the Real, the Imaginary, and the Symbolic helps analyze the relationship between the discourse and the silence of the unconscious. His essay on the “mirror stage” is useful for thinking about bourgeois subjectivity. Nevertheless, I argue that premissionization Shuar did not go through the mirror stage. First, I argue that Shuar practices effected the colonization of the Symbolic by the Real, in contrast to bourgeois culture, in which the Symbolic colonizes the Real. Then I explore the role of desire, violence, and speech in the construction of different kinds of power. Pierre Clastres’ work helps to explore how these two cultures clash and articulate on the colonization frontier, while psychoanalytic theory adds to Clastres a theory of the subject. Ultimately, this article is an experiment in acknowledging the psychic unity of humanity—while at the same time illuminating the differences between the state and societies against the state.

In this article, I discuss the changing meanings of tsantsas, the shrunken heads of enemies slain in war, for Shuar, a group indigenous to the Ecuadorian Amazon. By the time Ecuadorian authorities put an end to warfare in the 1950s, Shuar had exchanged all of their tsantsas with European and Euro-American collectors in return for trade goods. I focus on the continuing significance for Shuar of tsantsas, despite their absence, and the impact of the repatriation in 1995 of several heads by the National Museum of the American Indian. I suggest that, prior to colonization and missionization, Shuar headhunting was part of a larger system characterized by the circulation of powers that took multiple and changing forms. I further argue that as shrunken heads themselves began to circulate until they came to rest in Western collections and museums, their meaning was subordinated to a system in which power rests on the accumulation of values. After their long sojourn abroad, the heads now represent distance: the distance of contemporary Shuar from their past, and the distance between Shuar leaders and their constituents. The circulation of tsantsas over the past hundred years thus reveals transnational dimensions of power while simultaneously confounding simple distinctions between savagery and civilization.

This essay involves a set of speculations concerning the role plant-granted visions play in the formation of the Shuar subject. It also reflects on the need for an ethnography of secrecy and the ineffable. In both these tasks I seek to engage psychoanalytic theory. Jacques Lacan's distinction between the Real, the Imaginary, and the Symbolic helps analyze the relationship between the discourse and the silence of the unconscious. His essay on the \"mirror stage\" is useful for thinking about bourgeois subjectivity. Nevertheless, I argue that premissionization Shuar did not go through the mirror stage. First, I argue that Shuar practices effected the colonization of the Symbolic by the Real, in contrast to bourgeois culture, in which the Symbolic colonizes the Real. Then I explore the role of desire, violence, and speech in the construction of different kinds of power. Pierre Clastres' work helps to explore how these two cultures clash and articulate on the colonization frontier, while psychoanalytic theory adds to Clastres a theory of the subject. Ultimately, this article is an experiment in acknowledging the psychic unity of humanity-while at the same time illuminating the differences between the state and societies against the state. [PUBLICATION ABSTRACT]

This dissertation examines the construction of individual interests and group identity among Shuar, a group of 30-50,000 indigenous to the Ecuadorian Amazon. It focuses on conflicts that occur as people compete over resources as important locations of this process. By conflict I mean any struggle between individuals or groups, owing either to competing or contradictory interests. Although specific conflicts are evidence of tensions among and between individuals and communities, I view conflict neither as a disruption of social life nor as a homeostatic mechanism. Instead, I analyze conflict as a socially constructed context through which Shuar negotiate their dependence on and autonomy from both one another and other groups.

Cystic fibrosis transmembrane conductance regulator (CFTR) modulators correct the basic defect caused by CFTR mutations. Improvements in health outcomes have been achieved with the combination of a CFTR corrector and potentiator in people with cystic fibrosis homozygous for the F508del mutation. The addition of elexacaftor (VX-445), a next-generation CFTR corrector, to tezacaftor plus ivacaftor further improved F508del-CFTR function and clinical outcomes in a phase 2 study in people with cystic fibrosis homozygous for the F508del mutation. This phase 3, multicentre, randomised, double-blind, active-controlled trial of elexacaftor in combination with tezacaftor plus ivacaftor was done at 44 sites in four countries. Eligible participants were those with cystic fibrosis homozygous for the F508del mutation, aged 12 years or older with stable disease, and with a percentage predicted forced expiratory volume in 1 s (ppFEV1) of 40–90%, inclusive. After a 4-week tezacaftor plus ivacaftor run-in period, participants were randomly assigned (1:1) to 4 weeks of elexacaftor 200 mg orally once daily plus tezacaftor 100 mg orally once daily plus ivacaftor 150 mg orally every 12 h versus tezacaftor 100 mg orally once daily plus ivacaftor 150 mg orally every 12 h alone. The primary outcome was the absolute change from baseline (measured at the end of the tezacaftor plus ivacaftor run-in) in ppFEV1 at week 4. Key secondary outcomes were absolute change in sweat chloride and Cystic Fibrosis Questionnaire-Revised respiratory domain (CFQ-R RD) score. This study is registered with ClinicalTrials.gov, NCT03525548. Between Aug 3 and Dec 28, 2018, 113 participants were enrolled. Following the run-in, 107 participants were randomly assigned (55 in the elexacaftor plus tezacaftor plus ivacaftor group and 52 in the tezacaftor plus ivacaftor group) and completed the 4-week treatment period. The elexacaftor plus tezacaftor plus ivacaftor group had improvements in the primary outcome of ppFEV1 (least squares mean [LSM] treatment difference of 10·0 percentage points [95% CI 7·4 to 12·6], p<0·0001) and the key secondary outcomes of sweat chloride concentration (LSM treatment difference −45·1 mmol/L [95% CI −50·1 to −40·1], p<0·0001), and CFQ-R RD score (LSM treatment difference 17·4 points [95% CI 11·8 to 23·0], p<0·0001) compared with the tezacaftor plus ivacaftor group. The triple combination regimen was well tolerated, with no discontinuations. Most adverse events were mild or moderate; serious adverse events occurred in two (4%) participants receiving elexacaftor plus tezacaftor plus ivacaftor and in one (2%) receiving tezacaftor plus ivacaftor. Elexacaftor plus tezacaftor plus ivacaftor provided clinically robust benefit compared with tezacaftor plus ivacaftor alone, with a favourable safety profile, and shows the potential to lead to transformative improvements in the lives of people with cystic fibrosis who are homozygous for the F508del mutation. Vertex Pharmaceuticals.

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or \"high-risk.\" We evaluated whether a referral model would decrease high-risk patient costs. Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

Objective: Although data on publicly available special education are informative and offer a glimpse of trends in autism spectrum disorder (ASD) and use of educational services, using these data for population-based public health monitoring has drawbacks. Our objective was to evaluate trends in special education eligibility among 8-year-old children with ASD identified in the Autism and Developmental Disabilities Monitoring Network. Methods: We used data from 5 Autism and Developmental Disabilities Monitoring Network sites (Arizona, Colorado, Georgia, Maryland, and North Carolina) during 4 surveillance years (2002, 2006, 2008, and 2010) and compared trends in 12 categories of special education eligibility by sex and race/ethnicity. We used multivariable linear risk regressions to evaluate how the proportion of children with a given eligibility changed over time. Results: Of 6010 children with ASD, more than 36% did not receive an autism eligibility in special education in each surveillance year. From surveillance year 2002 to surveillance year 2010, autism eligibility increased by 3.6 percentage points (P = .09), and intellectual disability eligibility decreased by 4.6 percentage points (P < .001). A greater proportion of boys than girls had an autism eligibility in 2002 (56.3% vs 48.8%). Compared with other racial/ethnic groups, Hispanic children had the largest increase in proportion with autism eligibility from 2002 to 2010 (15.4%, P = .005) and the largest decrease in proportion with intellectual disability (–14.3%, P = .004). Conclusion: Although most children with ASD had autism eligibility, many received special education services under other categories, and racial/ethnic disparities persisted. To monitor trends in ASD prevalence, public health officials need access to comprehensive data collected systematically, not just special education eligibility.