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nenelonomh · 4 months ago

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skincare practices

skincare refers to the practice of maintaining and improving the health and appearance of your skin. this post is a guide on where to start!

having a routine (starting with simple practices)

cleanser: begin and end your day by washing your face with a gentle, sulphate-free cleanser. even if your skin feels clean, this step removes any impurities.

moisturizer: apply a fragrance-free moisturizer twice a day. hydration is crucial for maintaining a healthy skin barrier.

sunscreen: protect your skin from uv damage by using a mineral- or chemical-based sunscreen with at least spf 30. apply it in the morning.

skin types

there are 5 primary skin types, each with unique characteristics and needs.

normal skin is balanced and not too oily or dry. it's like the goldilocks of skin types! maintain it with a gentle routine. if your skin is generally normal, opt for a lotion. as you age, consider switching to a cream-based moisturizer for added hydration.

dry skin lacks hydration, feels tight, and may have flakiness. opt for richer moisturizers with ingredients like hyaluronic acid and ceramides. for dry skin, skip lotions and go for creams or ointments. these provide more moisture and help preserve water in the skin.

oily skin produces excess oil, especially in the t-zone (forehead, nose, and chin). use lightweight, oil-free products and consider salicylic acid for acne-prone areas. if you’re prone to oiliness, choose a light gel-based moisturizer to avoid clogging pores.

combination skin is a mix of oily and dry areas. focus on balancing - light moisturizers for oily zones and richer ones for dry areas. treat your face as two zones. moisturize the dry areas and skip the oily ones. remember to look for spf 30 or higher for sun protection!

sensitive skin is prone to redness, irritation, and reaction. choose fragrance-free, hypoallergenic products and patch-test any new products.

common skincare mistakes

skipping sunscreen. sunscreen is non-negotiable! protect your skin from uv damage by using spf 30 or higher daily. if you live in a sunny environment, make sure to reapply before you go outside!

not cleansing before bed: properly cleanse your face before sleeping. it removes dirt, makeup, excess oil, and pollution remnants, preventing breakouts and maintaining healthy skin.

sleeping with makeup on. gross! no! remove your makeup before you go to bed to prevent clogged pores and skin irritation.

using too many products. overloading with products can overwhelm your skin, so learn how to simplify your routine. additionally, using products that are not right for your skin may have negative effects - creating more issues instead of solving them.

overusing acne products. be gentle with acne treatments. overuse can lead to dryness and irritation.

using harsh products. avoid aggressive ingredients that strip your skin. opt for gentle formulations.

remember - healthy skin starts with mindful habits.

further reading

understanding skin - skin types and conditions | eucerin

what are skin types? | verywellhealth ↑ this link has a 'determining your skin type' section

how to pick the right moisturizer for your skin | american academy of dermatology association

combination skin care (youtube video) | dr. aanchal md

how to build a skincare routine for beginners | arizona dermatology

skin care: 5 tups for healthy skin | mayo clinic

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thank you for reading! i get a lot of skincare practice asks, so i figured it was about time i had a good response.

as always - if you're troubled by your skin take yourself to see a professional. they are specially trained to help you with your problems. this post will only be able to share with you what i have researched. definitely have a look into some of the 'further reading' links - it's so important to learn about (and determine your skin type).

if you'd like to have a look at more of my skincare posts, check out 'how to reduce acne - and what is acne?' and 'how to properly wash your face'. feel free to send any questions to my ask box!

❤️nene

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ficsbyuzi · 6 months ago

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All the ways lead to you - part 1

Characters: Aemond Targaryen, Inara Maegyr (Original female character) in a Modern HOTD AU

Warnings : FICTIONAL PLOTLINE. Established relationship. Me swooning over Aemond Targaryen and writing this🤭 Inara being a sweet and awesome girl.

Note: This post and that a mutual of mine (@/elegantsplendour) remarked that this fic series has 'Succession' vibes. I wasn't aware of the show when I wrote this last year, and I still haven't watched it. Any resemblance to its plot is purely coincidental. Everything that is going to be re-posted here, comes from my delulu mind.

Inara's thoughts and a little background about her are in italics.

Word count - 1.2k

"You know me, mom, I can't just start working in some random hospital as a junior doctor," Inara spoke to her mother on phone, cradling it between her ear and shoulder as she watered her kitchen plants on a Saturday afternoon, “I am trying to find a job where I can practice both medicine and my art.”

"Where on earth will you find such a job, Inara?" Her mom questioned disapprovingly. "You will soon be a licensed doctor and able to practice medicine. You should start with a clinician job and save up for your MD tuition."

"Let me at least try, Mum. Maybe I can join some makeup manufacturing labs or intern with those big-shot skincare providers."

Inara heard her mom sigh and tut in response to her plans, a reaction she was quite used to by now. Yet, the conviction in her voice didn't falter as she continued, "I will definitely enroll in an MD program. Don't worry.”

As long as Inara could remember, she had always loved makeup. Even as a child, she would rummage through her mom's makeup kits and spend hours in front of the mirror, painting her own face and sometimes her mother's.

Her parents always wished to see her in the white coat of a doctor - a dream she shared with them. Cracking the medical entrance exams straight out of high school was a cakewalk, her sharp intellect paving the way for her.

Despite plenty of medical schools in Essos, the allure of studying abroad was too strong and liberating. The prestige of the renowned Citadel Medical School in Westeros had captured her attention long ago, and securing a seat there felt like destiny fulfilled.

While medical school required her to focus entirely on classes and books, her creative side yearned for exploration. Her love for makeup never faded, and after dedicating half her life to studying, she decided to follow her heart. A heart that always danced between two worlds, two passions, yearning to embrace both simultaneously.

As soon as she adjusted to her new life on a foreign land, she enrolled into a weekend certification course near her medical school. And, thus began her journey towards becoming a rare combination of a licensed medical practitioner and a trained makeup artist.

Days blurred into nights as she balanced the demands of medical studies with the pursuit of her passion.

Six years flew by in a whirlwind of learning and she was now nearing the end of her curriculum. After the sixth and last month of her hospital training and formal graduation, she would be a licensed medical practitioner. Thanks to her dedication to both medicine and makeup, she now stood as a certified makeup artist, with an expertise in skin care and prosthetics.

After freelancing a bridal makeup assignment a couple of months ago, she decided to take a detour from a predictable route towards advanced degrees or clinical positions straight after college. She planned to give herself a year of exploration into other career options before enrolling into an MD in Dermatology. And so she made up her mind on freelancing or finding a job that could extend her stay in Westeros, thereby allowing her to save up for her MD.

"Anyway, you've been so busy with everything else, you haven't even thought about finding someone. You're not getting any younger!" Her mom steered the course of the conversation to the topic she dreaded the most.

Oh boy, here it comes!

The inevitable discussion about her biological clock and society's expectations for single women was about to begin.

"Mom, please, I'm twenty four, not forty four!"

"Yes, and about time you started thinking of settling down!"

Rolling her eyes, Inara let out a sharp sigh.

"I have chores to do, mum. I gotta go," she cut the conversation short, trying her best to hide her rising impatience, “Bye! Love you!”

"Fine, But please think about what I said. Love you. ”

After ending the call, Inara continued staring at her phone's home screen. Smiling faces of her family stared back.

Her mom’s words still lingered in her mind, as she made herself a cup of chamomile tea and settled herself infront of her laptop.

She sipped her tea, smiling and recalling her mom's statement about doing tons of different things at a time. She had always loved to hustle. And, she loved how chimeric her career goals were. It wasn't an easy road, but she was determined to make it work somehow. Career satisfaction had always been her first priority; finding someone to date or marry, wasn't.

Inara's attention snapped back to her laptop screen, her eyes widening as she noticed the fourth and fifth unread emails from the top. Both arrived around the same time from the job search website she had signed up for.

The subject of the first email read:

Requirement of an assistant make-up artist on an upcoming TV Show.

The second one read:

Requirement of a physician / medical officer(s) on a TV production.

Universe works in the strangest of ways. All you have to do is ask.

She quickly opened both emails in separate tabs. They were from the human resources department of a television production house in King’s Landing. A period drama based on mythological history was in pre-production, and the HR team was hiring people on contract basis.

As someone who rarely watched television,or movies, she chuckled at the thought of working on a TV production house. Nevertheless, she decided to give it a try. With a few quick clicks, she accessed the links for both the positions and uploaded her resume. As she crafted cover letters for each position, wishful thoughts surfaced again. She let out another exhilarating chuckle, as a wave of nervous excitement crawled down her spine.

How fun and cool it would be, if I could somehow do both the jobs simultaneously.

A week later, as Inara was on her way home from the hospital where she interned, her phone rang. Seeing a number with the King’s Landing code, she gasped.

With her heart alight with anticipation, she answered the call. Clearing her throat, she adopted her sweetest and most professional tone before greeting the caller.

"Hi, Dr. Maegyr, this is Stannis calling from the HR department at Red Keep Productions. We've shortlisted your resume for the opening we posted about. Will you be available for an interview next week?"

"Hello, Mr. Stannis. Sure, I...I will be available!" She tried her best to mask the excitement in her voice. "Uh, I applied for two positions. May I know which one I have been shortlisted for?"

"Dr. Maegyr, your profile is one of the most interesting we've received so far. You have been called to interview for both positions. I can't say with certainty right now if you'll be hired for one or both roles as that will be decided based on your performance in the interviews." She could sense his smile through the phone.

"Thank you," she mouthed, looking up, her amber eyes sparkling with gratitude.

---x----

Part 2

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invece-sto-sdraiato · 7 months ago

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My experience of watching House MD with my mom (a government certified dermatologist):

It was surprisingly such a bonding experience for us, now that I think about it. It was kind of our thing. I would ask her many questions about the technical stuff (biology lover here) and she would explain all of it to me. There were so many days when we would just discuss whatever happened in an episode, for hours. She didn’t mind any of the malpractice stuff (compared to what happens in Indian hospitals sometimes, house barely scratches the surface)

And I used to get so….idk exasperated at house’s cynicism towards others, while she didn’t give a thought about it. This is a woman who is currently in an administrative position (Associate Professor, to be exact) and she’s told me about the absolute shit some of her colleagues/subordinates have given her. I mean, she’s seen it all. She’s probably met people like house.

Coming back to the technics, she used to talk admiringly about how (mostly) accurate the med stuff was, and how there’s a lot of research gone into the writing of the show. And house’s discussion with the others using a whiteboard. I think that was what really made her like this show. I’ll elaborate.

This happened today:

Mom: “Last week, I was asking my students about the different dermatological diagnoses they’ve encountered in recent cases. And then, I asked them if any of them had ever watched House.” (She occasionally teaches post-graduate med students)

Me: “Really? Uh…. you asked them if they’ve watched House…of all the possible medical dramas?”

Mom: *eye roll* “Anyways, some of them said yes. And then I explained, how their method of determining the differential diagnosis is quite useful. Listing it all on a whiteboard, you know, it helps to clearly see where you stand and how to further proceed from there. And House gives the others freedom to express their opinions and doubts.”

Dad, suddenly: “He’ll list all possible diagnoses, and there’s times even when he has to strike out all of them. But none of them show any frustration and they keep brainstorming until they find the correct one. That can be so useful in daily life, you know?”

Me: “huh, I suppose you’re right.”

Dad: “They’re using something known as the ‘first principle thinking’ in psychology. It means that you refrain from making assumptions, and you go right to the basics, to find a solution.”

So. Idk what to say now. Maybe just that I have a lot of good memories pertaining to House. But obviously, being the teenager that I am, I was very interested in the hilson side of things (even if those two are seriously fucked up) but I also loved watching House for the technical stuff and used to get pretty excited if I even knew a bit about whatever illness was in an episode (a nerd’s a nerd 😅) sorry for the long post.

#well this was unexpected #I didn’t think it would get this long #I can’t help it can I #house md #just addie things #hate crimes md

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sanhatipal · 1 year ago

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VnC music box!!

Some big news for me: I qualified for MD Dermatology. The results came out a month and a half ago,and to celebrate I ordered, well commissioned,a VnC music box,with Legend if Blue Eyes from the anime OST. It finally got here,and I wanted to share!! I'm sorry I couldn't get absolute silence,that there's background noise,I live by a highway 🥲

The volume is too low,but I'll try to work around it. For now I put it in a lilac box and a blue butterfly on it, and am keeping it with the volumes(and my fluffy Luna) . To be honest,the melody isn't the most detailed either,and I do believe I can do better. But I can only do paper strips for the hand crank machine,not the wind up music box,so I don't regret it!

I got it from only one music box custom song ordering,since I did so,now if you want,you can get it for tiny bit less I believe,through "special tune" which are custom songs other people have already commissioned. I think.

#vanitas no carte #the case study of vanitas #vnc #vanitas no shuki #music box #vampire of the blue moon #i think it's fitting too..niw it's October

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diginerve · 4 months ago

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Vitiligo: Types, Symptoms, Causes & Treatment

Many postgraduate students preparing for their final examinations often struggle to get the right information on a particular topic at the right time and place. For instance, there may be many different sources on different topics that many students need help gathering.

What if a single course can provide you with complete information on every skin condition of dermatology, including Vitiligo?

Let's talk about everything you need to know about this skin condition. After that we can discuss an online course that allows students better to understand the required concepts and topics in Dermatology.

Vitiligo and its Types

Vitiligo is an autoimmune disease or skin disorder that causes the skin to lose color. People of any age, caste, or color can develop this skin disorder in the form of patches, and besides that, it can also affect hair, eyes, and inner ear.

Vitiligo is divided into various types, such as:

Acrofacial Vitiligo

Focal Vitiligo

Generalized Vitiligo

Universal Vitiligo

Mucosal Vitiligo

Symptoms of Vitiligo

Do you often see people with white patches on their hands or face? Well, this is a sign that they have developed this skin disorder. But what are its symptoms? How can someone know they are having this disease? Let's find out its signs and symptoms

Loss of skin color

Hearing loss

Itching

Premature white or gray hair

Spots of patches of white skin on different parts of the body

Causes of Vitiligo

Some people have different patches of white skin, and some have a lot of white skin all over their bodies. What causes Vitiligo to spread? Well, there can be many reasons why this happens, such as:

Genetic changes

Stress

Environmental triggers

Autoimmune condition

How to treat Vitiligo?

To diagnose Vitiligo, the medical practitioner will first ask about the patient’s history and perform various diagnostic tests like skin biopsy to treat this condition. Doctors may also use a special light called a Wood’s lamp to tell the difference between Vitiligo and other skin problems. After that, the doctor might recommend treatments like medication, light therapy, surgery, medications, etc.

Now, if you are a PG student and want to learn about it in depth and gain practical knowledge, you can enroll in an online dermatology course, which would be of great help.

About the Dermatology MD Course

Dermatology MD is a course curated by the top chief editors, Dr. Rashmi Sarkar and Dr. S. Sachhidanand, collaborating with India’s 78 eminent faculties. This e-course further includes the following:

Online video lectures on dermatology supported by benchmark/evidence-based studies.

110+ well-illustrated notes to help the students gain a thorough understanding of the concepts.

590+ self-assessment MCQ questions that can help in self-evaluation.

Different types of engagement activities to keep the students interested in the e-course

Dr. Wise's AI chatbot includes both practical and theoretical concepts.

Thus, if you want to make your career in this branch of medicine that deals with skin-related diseases, then this course is the right one for you!

Final Thoughts

Isn't it amazing that you have the best dermatology series to help you perform exceptionally well in exams? Then what’s taking you any longer? Enroll now in DigiNerve’s MD in Dermatology course!

#dermatology md #md in dermatology #dermatology course #online video lectures on dermatology #Focal Vitiligo #Universal Vitiligo #Mucosal Vitiligo #what causes vitiligo to spread #Skin Biopsy

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covid-safer-hotties · 2 days ago

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Also preserved in our archive

By John Jesitus

A population-based study has shown a slightly elevated risk for patients’ developing skin disorders, including alopecia areata (AA), alopecia totalis (AT), vitiligo, and bullous pemphigoid (BP), more than 6 months after COVID-19 infection. In addition, the authors reported that the COVID-19 vaccination appears to reduce these risks.

The study was published in JAMA Dermatology on November 6.

‘Compelling Evidence’ “This well-executed study by Heo et al. provides compelling evidence to support an association between COVID-19 infection and the development of subsequent autoimmune and autoinflammatory skin diseases,” wrote authors led by Lisa M. Arkin, MD, of the Department of Dermatology, University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin, in an accompanying editorial.

Using databases from Korea's National Health Insurance Service and the Korea Disease Control and Prevention Agency, investigators led by Yeon-Woo Heo, MD, a dermatology resident at Yonsei University Wonju College of Medicine, Wonju, Republic of Korea, compared 3.1 million people who had COVID-19 with 3.8 million controls, all with at least 180 days’ follow-up through December 31, 2022.

At a mean follow-up of 287 days in both cohorts, authors found significantly elevated risks for AA and vitiligo (adjusted hazard ratio [aHR], 1.11 for both), AT (aHR, 1.24), Behçet disease (aHR, 1.45), and BP (aHR, 1.62) in the post-COVID-19 cohort. The infection also raised the risk for other conditions such as systemic lupus erythematosus (aHR, 1.14) and Crohn’s disease (aHR, 1.35).

In subgroup analyses, demographic factors were associated with diverse effects: COVID-19 infection was associated with significantly higher odds of developing AA (for both men and women), vitiligo (men), Behçet disease (men and women), Crohn’s disease (men), ulcerative colitis (men), rheumatoid arthritis (men and women), systemic lupus erythematosus (men), ankylosing spondylitis (men), AT (women), and BP (women) than controls.

Those aged under 40 years were more likely to develop AA, primary cicatricial alopecia, Behçet disease, and ulcerative colitis, while those aged 40 years or older were more likely to develop AA, AT, vitiligo, Behçet disease, Crohn’s disease, rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrome, ankylosing spondylitis, and BP.

Additionally, severe COVID-19 requiring intensive care unit admission was associated with a significantly increased risk for autoimmune diseases, including AA, psoriasis, BP, and sarcoidosis. By timeframe, risks for AA, AT, and psoriasis were significantly higher during the initial Delta-dominant period.

Vaccination Effect Moreover, vaccinated individuals were less likely to develop AA, AT, psoriasis, Behçet disease, and various nondermatologic conditions than were those who were unvaccinated. This finding, wrote Heo and colleagues, “may provide evidence to support the hypothesis that COVID-19 vaccines can help prevent autoimmune diseases.”

“That’s the part we all need to take into our offices tomorrow," said Brett King, MD, PhD, a Fairfield, Connecticut-based dermatologist in private practice. He was not involved with the study but was asked to comment.

Overall, King said, the study carries two main messages. “The first is that COVID-19 infection increases the likelihood of developing an autoimmune or autoinflammatory disease in a large population.” The second and very important message, he added, is that being vaccinated against COVID-19 provides protection against developing an autoimmune or autoinflammatory disease.

“My concern is that the popular media highlights the first part,” said King, “and everybody who develops alopecia areata, vitiligo, or sarcoidosis blames COVID-19. That’s not what this work says.”

The foregoing distinction is especially important during the fall and winter, he added, when people getting influenza vaccines are routinely offered COVID-19 vaccines. “Many patients have said, ‘I got the COVID vaccine and developed alopecia areata 6 months later.’ Nearly everybody who has developed a new or worsening health condition in the last almost 5 years has had the perfect fall guy — the COVID vaccine or infection.”

With virtually all patients asking if they should get an updated COVID-19 vaccine or booster, he added, many report having heard that such vaccines cause AA, vitiligo, or other diseases. “To anchor these conversations in real data and not just anecdotes from a blog or Facebook is very useful,” said King, “and now we have very good data saying that the COVID vaccine is protective against these disorders.”

George Han, MD, PhD, associate professor of dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, applauds investigators’ use of a large, robust database but suggests interpreting results cautiously. He was not involved with the study but was asked to comment.

“You could do a large, well-done study,” Han said, “but it could still not necessarily be generalizable. These autoimmune conditions they’re looking at have clear ethnic and racial biases.” Heo and colleagues acknowledged shortcomings including their study population’s monomorphic nature.

Additional issues that limit the study’s impact, said Han, include the difficulty of conceptualizing a 10%-20% increase in conditions that at baseline are rare. And many of the findings reflected natural patterns, he said. For instance, BP more commonly affects older people, COVID-19 notwithstanding.

Han said that for him, the study’s main value going forward is helping to explain a rash of worsening inflammatory skin disease that many dermatologists saw early in the pandemic. “We would regularly see patients who were well controlled with, for example, psoriasis or eczema. But after COVID-19 infection or a vaccine (usually mRNA-type), in some cases they would come in flaring badly.” This happened at least a dozen times during the first year of post-shutdown appointments, he said.

“We’ve seen patients who have flared multiple times — they get the booster, then flare again,” Han added. Similar patterns occurred with pyoderma gangrenosum and other inflammatory skin diseases, he said.

Given the modest effect sizes of the associations reported in the Korean study, Arkin and colleagues wrote in their JAMA Dermatology editorial that surveillance for autoimmune disease is probably not warranted without new examination findings or symptoms. “For certain,” King said, “we should not go hunting for things that aren’t obviously there.”

Rather, Arkin and colleagues wrote, the higher autoimmunity rates seen among the unvaccinated, as well as during the Delta phase (when patients were sicker and hospitalizations were more likely) and in patients requiring intensive care, suggest that “interventions that reduce disease severity could also potentially reduce long-term risk of subsequent autoimmune sequelae.”

Future research addressing whether people with preexisting autoimmune conditions are at greater risk for flares or developing new autoimmune diseases following COVID-19 infection “would help to frame an evidence-based approach for patients with autoimmune disorders who develop COVID-19 infection, including the role for antiviral treatments,” they added.

The study was supported by grants from the Research Program of the Korea Medical Institute, the Korea Health Industry Development Institute, and the National Research Foundation of Korea. Han and King reported no relevant financial relationships. Arkin disclosed receiving research grants to her institution from Amgen and Eli Lilly and Company, personal fees from Sanofi/Regeneron for consulting, and personal consulting fees from Merck outside the submitted work. Another author reported personal consulting fees from Dexcel Pharma and Honeydew outside the submitted work. No other disclosures were reported.

Study Link: jamanetwork.com/journals/jamadermatology/article-abstract/2825849 (PAYWALLED)

#mask up #public health #wear a mask #pandemic #covid #wear a respirator #covid 19 #still coviding #coronavirus #sars cov 2 #long covid #covid is airborne #covid is not over #covid conscious

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mostlysignssomeportents · 2 years ago

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The antitrust Twilight Zone

Funeral homes were once dominated by local, family owned businesses. Today, odds are, your neighborhood funeral home is owned by Service Corporation International, which has bought hundreds of funeral homes (keeping the proprietor’s name over the door), jacking up prices and reaping vast profits.

Funeral homes are now one of America’s most predatory, vicious industries, and SCI uses the profits it gouges out of bereaved, reeling families to fuel more acquisitions — 121 more in 2021. SCI gets some economies of scale out of this consolidation, but that’s passed onto shareholders, not consumers. SCI charges 42% more than independent funeral homes.

https://pluralistic.net/2022/09/09/high-cost-of-dying/#memento-mori

SCI boasts about its pricing power to its investors, how it exploits people’s unwillingness to venture far from home to buy funeral services. If you buy all the funeral homes in a neighborhood, you have near-total control over the market. Despite these obvious problems, none of SCI’s acquisitions face any merger scrutiny, thanks to loopholes in antitrust law.

These loopholes have allowed the entire US productive economy to undergo mass consolidation, flying under regulatory radar. This affects industries as diverse as “hospital beds, magic mushrooms, youth addiction treatment centers, mobile home parks, nursing homes, physicians’ practices, local newspapers, or e-commerce sellers,” but it’s at its worst when it comes to services associated with trauma, where you don’t shop around.

Think of how Envision, a healthcare rollup, used the capital reserves of KKR, its private equity owner, to buy emergency rooms and ambulance services, elevating surprise billing to a grotesque art form. Their depravity knows no bounds: an unconscious, intubated woman with covid was needlessly flown 20 miles to another hospital, generating a $52k bill.

https://pluralistic.net/2022/03/14/unhealthy-finances/#steins-law

This is “the health equivalent of a carjacking,” and rollups spread surprise billing beyond emergency rooms to anesthesiologists, radiologists, family practice, dermatology and others. In the late 80s, 70% of MDs owned their practices. Today, 70% of docs work for a hospital or corporation.

How the actual fuck did this happen? Rollups take place in “antitrust’s Twilight Zone,” where a perfect storm of regulatory blindspots, demographic factors, macroeconomics, and remorseless cheating by the ultra-wealthy has laid waste to the American economy, torching much of the US’s productive capacity in an orgy of predatory, extractive, enshittifying mergers.

The processes that underpin this transformation aren’t actually very complicated, but they are closely interwoven and can be hard to wrap your head around. “The Roll-Up Economy: The Business of Consolidating Industries with Serial Acquisitions,” a new paper from The American Economic Liberties Project by Denise Hearn, Krista Brown, Taylor Sekhon and Erik Peinert does a superb job of breaking it down:

http://www.economicliberties.us/wp-content/uploads/2022/12/Serial-Acquisitions-Working-Paper-R4-2.pdf

The most obvious problem here is with the MergerScrutiny process, which is when competition regulators must be notified of proposed mergers and must give their approval before they can proceed. Under the Hart-Scott-Rodino Act (HSR) merger scrutiny kicks in for mergers when the purchase price is $101m or more. A company that builds up a monopoly by acquiring hundreds of small businesses need never face merger scrutiny.

The high merger scrutiny threshold means that only a very few mergers are regulated: in 2021, out of 21,994 mergers, only 4,130 (<20%) were reported to the FTC. 2020 saw 16,723 mergers, with only 1.637 (>10%) being reported to the FTC.

Serial acquirers claim that the massive profits they extract by buying up and merging hundreds of businesses are the result of “efficiency” but a closer look at their marketplace conduct shows that most of those profits come from market power. Where efficiences are realized, they benefit shareholders, and are not shared with customers, who face higher prices as competition dwindles.

The serial acquisition bonanza is bad news for supply chains, wages, the small business ecosystem, inequality, and competition itself. Wherever we find concentrated industires, we find these under-the-radar rollups: out of 616 Big Tech acquisitions from 2010 to 2019, 94 (15%) of them came in for merger scrutiny.

The report’s authors quote FTC Commissioner Rebecca Slaughter: “I think of serial acquisitions as a Pac-Man strategy. Each individual merger viewed independently may not seem to have significant impact. But the collective impact of hundreds of smaller acquisitions, can lead to a monopolistic behavior.”

It’s not just the FTC that recognizes the risks from rollups. Jonathan Kanter, the DoJ’s top antitrust enforcer has raised alarms about private equity strategies that are “designed to hollow out or roll-up an industry and essentially cash out. That business model is often very much at odds with the law and very much at odds with the competition we’re trying to protect.”

The DoJ’s interest is important. As with so many antitrust failures, the problem isn’t in the law, but in its enforcement. Section 7 of the Clayton Act prohibits serial acquisitions under its “incipient monopolization” standard. Acquisitions are banned “where the effect of such acquisition may be to substantially lessen competition between the corporation whose stock is so acquired and the corporation making the acquisition.” This incipiency standard was strengthened by the 1950 Celler-Kefauver Amendment.

The lawmakers who passed both acts were clear about their legislative intention — to block this kind of stealth monopoly formation. For decades, that’s how the law was enforced. For example, in 1966, the DoJ blocked Von’s from acquiring another grocer because the resulting merger would give Von’s 7.5% of the regional market. While Von’s is cited by pro-monopoly extremists as an example of how the old antitrust system was broken and petty, the DoJ’s logic was impeccable and sorely missed today: they were trying to prevent a rollup of the sort that plagues our modern economy.

As the Supremes wrote in 1963: “A fundamental purpose of [stronger incipiency standards was] to arrest the trend toward concentration, the tendency of monopoly, before the consumer’s alternatives disappeared through merger, and that purpose would be ill-served if the law stayed its hand until 10, or 20, or 30 [more firms were absorbed].”

But even though the incipiency standard remains on the books, its enforcement dwindled away to nothing, starting in the Reagan era, thanks to the Chicago School’s influence. The neoliberal economists of Chicago, led by the Nixonite criminal Robert Bork, counseled that most monopolies were “efficient” and the inefficient ones would self-correct when new businesses challenged them, and demanded a halt to antitrust enforcement.

In 1982, the DoJ’s merger guidelines were gutted, made toothless through the addition of a “safe harbor” rule. So long as a merger stayed below a certain threshold of market concentration, the DoJ promised not to look into it. In 2000, Clinton signed an amendment to the HSR Act that exempted transactions below $50m. In 2010, Obama’s DoJ expanded the safe harbor to exclude “[mergers that] are unlikely to have adverse competitive effects and ordinarily require no further analysis.”

These constitute a “blank check” for serial acquirers. Any investor who found a profitable strategy for serial acquisition could now operate with impunity, free from government interference, no matter how devastating these acquisitions were to the real economy.

Unfortunately for us, serial acquisitions are profitable. As an EY study put it: “the more acquisitive the company… the greater the value created…there is a strong pattern of shareholder value growth, correlating with frequent acquisitions.” Where does this value come from? “Efficiencies” are part of the story, but it’s a sideshow. The real action is in the power that consolidation gives over workers, suppliers and customers, as well as vast, irresistable gains from financial engineering.

In all, the authors identify five ways that rollups enrich investors:

I. low-risk expansion;

II. efficiencies of scale;

III. pricing power;

IV. buyer power;

V. valuation arbitrage.

The efficiency gains that rolled up firms enjoy often come at the expense of workers — these companies shed jobs and depress wages, and the savings aren’t passed on to customers, but rather returned to the business, which reinvests it in gobbling up more companies, firing more workers, and slashing survivors’ wages. Anything left over is passed on to the investors.

Consolidated sectors are hotbeds of fraud: take Heartland, which has rolled up small dental practices across America. Heartland promised dentists that it would free them from the drudgery of billing and administration but instead embarked on a campaign of phony Medicare billing, wage theft, and forcing unnecessary, painful procedures on children.

Heartland is no anomaly: dental rollups have actually killed children by subjecting them to multiple, unnecessary root-canals. These predatory businesses rely on Medicaid paying for these procedures, meaning that it’s only the poorest children who face these abuses:

https://pluralistic.net/2022/11/17/the-doctor-will-fleece-you-now/#pe-in-full-effect

A consolidated sector has lots of ways to rip off the public: they can “directly raise prices, bundle different products or services together, or attach new fees to existing products.” The epidemic of junk fees can be traced to consolidation.

Consolidators aren’t shy about this, either. The pitch-decks they send to investors and board members openly brag about “pricing power, gained through acquisitions and high switching costs, as a key strategy.”

Unsurprisingly, investors love consolidators. Not only can they gouge customers and cheat workers, but they also enjoy an incredible, obscure benefit in the form of “valuation arbitrage.”

When a business goes up for sale, its valuation (price) is calculated by multiplying its annual cashflow. For small businesses, the usual multiplier is 3–5x. For large businesses, it’s 10–20x or more. That means that the mere act of merging a small business with a large business can increase its valuation sevenfold or more!

Let’s break that down. A dental practice that grosses $1m/year is generally sold for $3–5m. But if Heartland buys the practice and merges it with its chain of baby-torturing, Medicaid-defrauding dental practices, the chain’s valuation goes up by $10–20m. That higher valuation means that Heartland can borrow more money at more favorable rates, and it means that when it flips the husks of these dental practices, it expects a 700% return.

This is why your local veterinarian has been enshittified. “A typical vet practice sells for 5–8x cashflow…American Veterinary Group [is] valued at as much as 21x cashflow…When a large consolidator buys a $1M cashflow clinic, it may cost them as little as $5M, while increasing the value of the consolidator by $21M. This has created a goldrush for veterinary consolidators.”

This free money for large consolidators means that even when there are better buyers — investors who want to maintain the quality and service the business offers — they can’t outbid the consolidators. The consolidators, expecting a 700% profit triggered by the mere act of changing the business’s ownership papers, can always afford to pay more than someone who merely wants to provide a good business at a fair price to their community.

To make this worse, an unprecedented number of small businesses are all up for sale at once. Half of US businesses are owned by Boomers who are ready to retire and exhausted by two major financial crises within a decade. 60% of Boomer-owned businesses — 2.9m businesses of 11 or so employees each, employing 32m people in all — are expected to sell in the coming decade.

If nothing changes, these businesses are likely to end up in the hands of consolidators. Since the Great Financial Crisis of 2008, private equity firms and other looters have been awash in free money, courtesy of the Federal Reserve and Congress, who chose to bail out irresponsible and deceptive lenders, not the borrowers they preyed upon.

A decade of zero interest rate policy (ZIRP) helped PE grow to “staggering” size. Over that period, America’s 2,000 private equity firms raised buyout warchests totaling $2t. Today, private equity owned companies outnumber publicly traded firms by more than two to one.

Private equity is patient zero in the serial acquisition epidemic. The list of private equity rollup plays includes “comedy clubs, ad agencies, water bottles, local newspapers, and healthcare providers like hospitals, ERs, and nursing homes.”

Meanwhile, ZIRP left the nation’s pension funds desperate for returns on their investments, and these funds handed $480b to the private equity sector. If you have a pension, your retirement is being funded by investments that are destroying your industry, raising your rent, and turning the nursing home you’re doomed to into a charnel house.

The good news is that enforcers like Kanter have called time on the longstanding, bipartisan failure to use antitrust laws to block consolidation. Kanter told the NY Bar Association: “We have an obligation to enforce the antitrust laws as written by Congress, and we will challenge any merger where the effect ‘may be substantially to lessen competition, or to tend to create a monopoly.’”

The FTC and the DOJ already have many tools they can use to end this epidemic.

They can revive the incipiency standard from Sec 7 of the Clayton Act, which bans mergers where “the effect of such acquisition may be substantially to lessen competition, or to tend to create a monopoly.”

This allows regulators to “consider a broad range of price and non-price effects relevant to serial acquisitions, including the long-term business strategy of the acquirer, the current trend or prevalence of concentration or acquisitions in the industry, and the investment structure of the transactions”;

The FTC and DOJ can strengthen this by revising their merger guidelines to “incorporate a new section for industries or markets where there is a trend towards concentration.” They can get rid of Reagan’s 1982 safe harbor, and tear up the blank check for merger approval;

The FTC could institute a policy of immediately publishing merger filings, “the moment they are filed.”

Beyond this, the authors identify some key areas for legislative reform:

Exempt the FTC from the Paperwork Reduction Act (PRA) of 1995, which currently blocks the FTC from requesting documents from “10 or more people” when it investigates a merger;

Subject any company “making more than 6 acquisitions per year valued at $70 million total or more” to “extra scrutiny under revised merger guidelines, regardless of the total size of the firm or the individual acquisitions”;

Treat all the companies owned by a PE fund as having the same owner, rather than allowing the fiction that a holding company is the owner of a business;

Force businesses seeking merger approval to provide “any investment materials, such as Private Placement Memorandums, Management or Lender Presentations, or any documents prepared for the purposes of soliciting investment. Such documents often plainly describe the anticompetitive roll-up or consolidation strategy of the acquiring firm”;

Also force them to provide “loan documentation to understand the acquisition plans of a company and its financing strategy;”

When companies are found to have violated antitrust, ban them from acquiring any other company for 3–5 years, and/or force them to get FTC pre-approval for all future acquisitions;

Reinvigorate enforcement of rules requiring that some categories of business (especially healthcare) be owned by licensed professionals;

Lower the threshold for notification of mergers;

Add a new notification requirement based on the number of transactions;

Fed agencies should automatically share merger documents with state attorneys general;

Extend civil and criminal antitrust penalties to “investment bankers, attorneys, consultants who usher through anticompetitive mergers.”

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archiveofkloss · 9 months ago

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vogue: “Karlie Kloss and Tabria Majors Discuss the Physical Toll (and Joy) of Motherhood” by Audrey Noble

“Are you by chance part of the mom tribe?” Karlie Kloss asks me over the phone. It’s a natural—even expected—start to our conversation about the model and entrepreneur’s latest campaign for diaper brand Coterie, which is all about celebrating the physical journey of motherhood.

Though I am very much in my single, child-free era, motherhood is something that I hope is in the cards for me. And it is Kloss’s and fellow model and Coterie campaign costar Tabria Majors’s palpable excitement on my respective phone calls with each where they gushed about their little ones that strengthened my resolve to have a family of my own one day. (So much so, that I may or may not have enlisted their help to manifest it for me). Simply put: They love beings moms.

“It’s the greatest experience in my life,” Kloss tells Vogue. “I mean, maybe it’s the hormones, but it just gives me the greatest joy every single day to wake up and have these two little delicious humans whom I just love so much.”

“It’s just crazy to see how much she’s changed and seeing her little personality developing,” Majors says of her six-month-old daughter. “Just seeing her laugh all the time, it just warms my heart.”

The campaign, which debuted in early February, features Kloss (who invested in the Coterie late last year); Majors; board-certified pediatrician Dr. Mona Amin, MD; celebrity nail artist Mei Kawajiri; and influencer Reese Blutstein, sharing their pregnancy stories in hopes of inspiring others who might be struggling with the changes to their bodies—which is a topic that isn’t often spoken about.

Studies show that the rib cage can expand two to three inches and ligaments can stretch between the second and third trimester. According to the Mayo Clinic, the heart pumps 50 percent more blood to nourish the baby, while the American Academy of Dermatology notes that hair loss is prevalent in new moms. When you pair systemic failures in proper reproductive education with societal expectations to look “perfect” 24/7, many might feel confused and discouraged when witnessing their bodies go through major changes.

“You kind of just have to trust the process. I have learned to love and respect my body through this process, and with that comes changes,” says Kloss. “Of course, I have all the things like stretch marks and all the fun post-baby body things that I’m not mad at. They make me who I am, and I’m so grateful for that.”

Pre- and post-pregnancy can be a lonely experience, even if you are lucky enough to have a full support system. Which is why Majors says sharing pregnancy stories is important to help people feel less alone. She tells me about the outpour of love and support from fans over her birthing story has been an emotional, yet beautiful experience. She even recalls one woman messaging her and saying that her story encouraged her to proceed with her own home birthing—something that Majors says she will never forget. “I just thought that was really powerful and inspiring for me,” she says. “That just makes me feel really good that my story could impact somebody in such a way.”

It would be remiss to not acknowledge that the launch of Coterie’s campaign coincidently coincides with news of the Alabama Supreme Court ruling that embryos created through in vitro fertilization (IVF) are considered people, putting the legality of the procedure into question and further harming reproductive health care. The fight to protect reproductive rights is at the forefront during what is shaping to be a contentious presidential election year. These issues are not lost on either Kloss or Majors, who both intentionally pick brand partnerships that not only align with their personal beliefs but can also help make a difference. Both credit Coterie for creating a safe space for women to advocate for themselves.

“[I] hate that our bodies are being policed; I don’t understand how that’s even a thing. It makes no sense,” says Majors. “I think that’s why it's important for these partnerships to happen. [But] even outside of partnerships, you don’t have to be paid to speak up. You should just want to speak up naturally because this affects everybody on such a macro level.”

“It’s an individual's choice if and when they’re ready to become a parent. This is such a profound life change in every way and I think it should be an individual’s choice if and when they’re ready for that,” adds Kloss. “It [has] only reconfirmed my passion and commitment to fighting for reproductive rights, certainly in every state in this country.”

I ask them what’s the best mom advice they’ve received, and both give two truths that could be applied to all facets of life: Trust the timing of the universe and trust yourself. “You just have to learn to roll with the punches,” says Kloss. “Motherhood is messy and amazing. I think [it has] actually been so important for me to be more comfortable with not being able to control everything because that’s just the way it goes.”

“Trust your gut, trust your instinct,” adds Majors. “Especially as a first-time parent, you think that you don’t know anything (and you don’t), but you figure it out as you go along. And even if you didn’t research yourself to death, which I know everybody does nowadays, you will know what to do. You will figure out what to do. Your instincts will kick in, and it’s just a crazy feeling.”

Noted for my future self.

#karlie kloss #vogue #interview #vogue interview #coterie #article

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