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This Article examines a controversial national security measure: the use of the armed forces within domestic borders. Military policing blurs the boundaries between crime and war, and tends to entail greater use of force against individuals. It has received relatively little academic attention but deserves to be better understood. No democratic state has relied on military policing for longer than India. And within India, no region has been subject to military policing for as long as the northeastern state of Manipur. I analyze how military policing in Manipur has fostered abuse by the armed forces, which in turn has prompted litigation and judicial innovation. Based on my analysis, I critique dominant theories about the state’s exceptional security powers. I advance two main claims. First, exceptional powers rarely remain exceptional; they eventually become the norm. Once deployed, these powers persist, and the license they provide seeps into broader habits of governance. Second, once normalized, exceptional powers become more vulnerable to judicial intervention. Judges become unwilling to accept the government’s argument that these powers are always and only used to fight pressing threats. These powers eventually become a routine subject of judicial review. Even once judicial review becomes routine, however, judges tend to be more willing to help victims of abuse than to punish abusers.
A multiproxy study involving sedimentology, palynology, radiocarbon dating, stable isotopes, and geochemistry was carried out on the Parsons Valley Lake deposit, Nilgiris, India, to determine palaeoclimatic fluctuations and their possible impact on vegetation since the late Pleistocene. The 72-cm-deep sediment core that was retrieved reveals five distinct palaeoclimatic phases: (1) Warm and humid conditions with a high lake stand before the last glacial maximum (LGM; ~29,800 cal yr BP), subsequently changing to a relatively cool and dry phase during the LGM. (2) Considerable dry conditions and lower precipitation occurred between ~16,300 and 9500 cal yr BP. During this period, the vegetation shrank and perhaps was confined to moister pockets or was a riparian forest cover. (3) An outbreak in the shift of monsoonal precipitation was witnessed in the beginning of the mid-Holocene, around 8400 cal yr BP, implying alteration in the shift toward warm and humid conditions, resulting in relatively high pollen abundance for evergreen taxa. (4) This phase exhibits a shift to heavier δ13C values around ~1850 cal yr BP, with an emergence of moist deciduous plants pointing to drier conditions. (5) Human activities contributed to the exceedingly high percentage of Acacia and Pinus pollen during the Little Ice Age.
Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals.
In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap.
Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity.
ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a “whole hospital” problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.
Body image is a vital and complex issue in cancer patients, but not well recognized. In the ambulatory psychiatric-oncology clinic, we assessed what portion of cancer patients endorsed appearance problems and if they differed in terms of depression, anxiety, or distress scores when compared with those who did not endorse appearance problems.
All adult patients with active cancer diagnosis seen in the outpatient psychiatry oncology clinic (June 2014–January 2016) who provided informed consent were included (N = 1,939) in the cross-sectional study design. “Appearance problems” were assessed as a categorical, binomial variable (yes/no) using the National Comprehensive Cancer Network Distress Thermometer checklist. Other assessments included the Patient Health Questionnaire-9, Patient Health Questionnaire-2, Generalized Anxiety Disorder-7, Distress Thermometer, and Edmonton Symptom Assessment Scale.
The overall prevalence rate of individuals who endorsed appearance problems was approximately 36%; they were more likely to be younger, female, Black or Hispanic, and not in a committed relationship (all results for demographic variables were statistically significant; all p < .001). Importantly, those patients who endorsed appearance problems exhibited higher scores for depression (p < .0001), anxiety (p < .0001), and distress (p < .0001), and these differences were of medium effect size (Cohen's d = 0.5−0.6).
Significance of results
The current results underscore the need to identify patients with body image problems early given that they are likely to exhibit higher magnitude of anxiety, depression and distress symptoms while undergoing cancer care. The results highlight the importance of body image issues and the need to evaluate them in cancer patients.
The transfer of pathogens may spread antimicrobial resistance and lead to healthcare-acquired infections. We performed a systematic literature review to generate estimates of pathogen transfer in relation to healthcare provider (HCP) activities.
For this systematic review and meta-analysis, Medline/Ovid, EMBASE, and the Cochrane Library were searched for studies published before July 7, 2017. We reviewed the literature, examining transfer of pathogens associated with HCP activities. We included studies that (1) quantified transfer of pathogens from a defined origin to a defined destination surface; (2) reported a microbiological sampling technique; and (3) described the associated activity leading to transfer. For studies reporting transfer frequencies, we extracted data and calculated the estimated proportion using Freeman-Tukey double arcsine transformation and the DerSimonian-Laird random-effects model.
Of 13,121 identified articles, 32 were included. Most articles (n=27, 84%) examined transfer from patients and their environment to HCP hands, gloves, and gowns, with an estimated proportion for transfer frequency of 33% (95% confidence interval [CI], 12%–57%), 30% (95% CI, 23%–38%) and 10% (95% CI, 6%–14%), respectively. Other articles addressed transfer involving the hospital environment and medical devices. Risk factor analyses in 12 studies suggested higher transfer frequencies after contact with moist body sites (n=7), longer duration of care (n=5), and care of patients with an invasive device (n=3).
Recognizing the heterogeneity in study designs, the available evidence suggests that pathogen transfer to HCPs occurs frequently. More systematic research is urgently warranted to support targeted and economic prevention policies and interventions.
To investigate discrepancies in dose calculation algorithms used for lung stereotactic body radiotherapy (SBRT) plans.
Methods and materials
In total, 30 patients lung SBRT treatment plans, initially generated using BrainLab Pencil Beam (BL_PB) algorithm for 10 Gy×5 Fractions to the planning target volume (PTV) were included in the study. These plans were recalculated using BrainLab Monte Carlo (BL_MC), Eclipse AAA (EC_AAA), Eclipse Acuros XB (EC_AXB) and ADAC Pinnacle CCC (AP_CCC) algorithms. Dose volume histograms of PTV were used to calculate dosimetric and radiobiological quality indices, and equivalent dose to 2 Gy per fraction using linear-quadratic-linear model. The BL_MC algorithm is considered gold standard tool to compare PTV parameters and quality indices to investigate dose calculation discrepancies of abovementioned plans.
BL_PB overestimates doses that may be due to inability of the algorithm to properly account for electron scattering and transport in inhomogeneous medium. Compared with BL_MCNO plans, the EC_AAA and EC_AXB yield lower homogeneity indices and overestimate the dose in the penumbra region, whereas AP_CCC plans were comparable for small PTV (≈8 cc) and had significant difference for large PTV.
BL_PB algorithm overestimates PTV doses than BL_MC calculated doses. The EC_AAA, EC_AXB and AP_CCC algorithms calculate doses within acceptable limits of radiotherapy dose delivery recommendations.
The main challenges of developing advanced surface-enhanced Raman spectroscopy (SERS) sensors lie in the poor reproducibility, low uniformity, and the lack of molecular selectivity. In this paper, we report a facile and cost-effective approach for the large-scale patterning of graphene-encapsulated Au nanoparticles on Si substrate as efficient SERS sensors with highly-improved uniformity, reproducibility, and unique selectivity. The materials production was accomplished via an industry-applicable galvanic deposition—annealing—chemical vapor deposition approach, followed by a final plasma treatment. Our study provides a facile approach to the fabrication of uniform SERS substrate and further prompts the practical progress of SERS-based chemical sensors.
Central line-associated bloodstream infection (CLABSI) is associated with significant morbidity and mortality. Despite a nationwide decline in CLABSI rates, individual hospital success in preventing CLABSI is variable. Difficulty in interpreting and applying complex CLABSI metrics may explain this problem. Therefore, we assessed expert interpretation of CLABSI quality data. DESIGN. Cross-sectional survey PARTICIPANTS. Members of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) METHODS. We administered a 10-item test of CLABSI data comprehension. The primary outcome was percent correct of attempted questions pertaining to the CLABSI data. We also assessed expert perceptions of CLABSI reporting.
The response rate was 51% (n=67).Among experts, the average proportion of correct responses was 73% (95% confidence interval [CI], 69%–77%). Expert performance on unadjusted data was significantly better than risk-adjusted data (86% [95% CI, 81%–90%] vs 65% [95% CI, 60%–70%]; P<.001). Using a scale of 1 to 100 (0, never reliable; 100, always reliable), experts rated the reliability of CLABSI data as 61. Perceived reliability showed a significant inverse relationship with performance (r=–0.28; P=.03), and as interpretation of data improved, perceptions regarding reliability of those data decreased. Experts identified concerns regarding understanding and applying CLABSI definitions as barriers to care.
Significant variability in the interpretation of CLABSI data exists among experts. This finding is likely related to data complexity, particularly with respect to risk-adjusted data. Improvements appear necessary in data sharing and public policy efforts to account for this complexity.
To determine features associated with better perceived quality of training for psychiatrists on advance decision-making in the Mental Capacity Act 2005 (MCA), and whether the quality or amount of training were associated with positive attitudes or use of advance decisions to refuse treatment (ADRTs) by psychiatrists in people with bipolar disorder. An anonymised national survey of 650 trainee and consultant psychiatrists in England and Wales was performed.
Good or better quality of training was associated with use of case summaries, role-play, ADRTs, assessment of mental capacity and its fluctuation. Good or better quality and two or more sessions of MCA training were associated with more positive attitudes and reported use of ADRTs, although many psychiatrists would never discuss them clinically with people with bipolar disorder.
Consistent delivery of better-quality training is required for all psychiatrists to increase use of ADRTs in people with bipolar disorder.
Peripherally inserted central catheters (PICCs) are associated with central-line–associated bloodstream infections (CLABSIs). However, no tools to predict risk of PICC-CLABSI have been developed.
To operationalize or prioritize CLABSI risk factors when making decisions regarding the use of PICCs using a risk model to estimate an individual’s risk of PICC-CLABSI prior to device placement.
Using data from the Michigan Hospital Medicine Safety consortium, patients that experienced PICC-CLABSI between January 2013 and October 2016 were identified. A Cox proportional hazards model with robust sandwich standard error estimates was then used to identify factors associated with PICC-CLABSI. Based on regression coefficients, points were assigned to each predictor and summed for each patient to create the Michigan PICC-CLABSI (MPC) score. The predictive performance of the score was assessed using time-dependent area-under-the-curve (AUC) values.
Of 23,088 patients that received PICCs during the study period, 249 patients (1.1%) developed a CLABSI. Significant risk factors associated with PICC-CLABSI included hematological cancer (3 points), CLABSI within 3 months of PICC insertion (2 points), multilumen PICC (2 points), solid cancers with ongoing chemotherapy (2 points), receipt of total parenteral nutrition (TPN) through the PICC (1 point), and presence of another central venous catheter (CVC) at the time of PICC placement (1 point). The MPC score was significantly associated with risk of CLABSI (P<.0001). For every point increase, the hazard ratio of CLABSI increased by 1.63 (95% confidence interval, 1.56–1.71). The area under the receiver-operating-characteristics curve was 0.67 to 0.77 for PICC dwell times of 6 to 40 days, which indicates good model calibration.
The MPC score offers a novel way to inform decisions regarding PICC use, surveillance of high-risk cohorts, and utility of blood cultures when PICC-CLABSI is suspected. Future studies validating the score are necessary.
Introduction: Emergency department (ED) access block is the #1 safety concern in Canadian EDs. Its main cause is hospital access block, manifested by prolonged boarding of inpatients in EDs. Hospital administrators often believe this problem is too big to be solved and would require large increases in hospital capacity. Our objective was to quantify ED access gap by estimating the cumulative hours that CTAS 1-3 patients are blocked in waiting areas. This value, expressed as a proportion of inpatient care capacity, is an estimate of the bed hours a hospital would have to find in order to resolve ED access. Methods: A convenience sample of urban Canadian ED directors were asked to provide data summarizing their CTAS 1-3 inflow, the proportion triaged to nursed stretchers vs. RAZ or Intake areas, and time to care space. Total ED access gap was calculated by multiplying the number of CTAS 1-3 patients by their average delay to care space. Time to stretcher was captured electronically at participating sites, but time to RAZ or intake spaces was often not. In such cases, respondents provided time from triage to first RN or MD assessment in these areas. The primary outcome was total annual ED access block hours for emergent-urgent patients, expressed as a proportion of funded inpatient bed hours. Results: Directors of 40 EDs were queried. Six sites did not gather the data elements required. Of 34 remaining, 29 (85.3%) provided data, including 15 tertiary (T), 10 community (C) and 2 pediatric (P) sites in 12 cities. Mean census for the 3 ED types was 72,308 (T), 58,849 C) and 61,050 (P) visits per year. CTAS 1-3 patients accounted for 73.4% (T), 67.7% (C) and 66.2% (P) of visits in the 3 groups, and 34% (T), 46% (C) and 44% (P) of these patients were treated in RAZ or intake areas rather than staffed ED stretchers. Mean time to stretcher/RAZ care was 50/71 min (T), 46/62 min (C), and 37/59 min (P). Average ED access gap was 47,564 hrs (T), 37,222 hrs (C) and 35,407 hrs (P), while average inpatient bed capacity was 599 beds (5,243,486 hrs), 291 beds (2,545,875 hrs) and 150 beds (1,314,000 hrs) respectively. ED access gap as a proportion of inpatient care capacity was 0.93% for tertiary, 1.46% for community and 2.69% for pediatric centres. Conclusion: ED access gap is very large in Canadian EDs, but small compared to hospital operating capacity. Hospital capacity or efficiency improvements in the range of 1-3% could profoundly mitigate ED access block.