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Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures & Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.
Stigmatizing attitudes regarding mentally ill people are common (Rusch et al., 2010). Study result suggest that the degree of stigmatization may depend on concepts of psychiatric diseases (Crisafulli et al., 2008).
We aimed to investigate the impact of a sole neurobiological vs. a sole sociodynamic disease concept on the attitudes of students towards the alcohol dependent patients (Crisafulli et al., 2008).
200 students were randomly assigned to read information explaining alcohol dependence sole neurobiologically/sociodynamically. Subsequently, the students completed a series of questionnaires (adapted from Crisafulli et al. (2008)) regarding their attitudes towards the alcohol dependent patients. Attitudes were compared to attitudes of students not exposed to any disease concept.
Consistent with former study results we found increased blaming and decreased willingness to finance therapy in those students exposed to the sociodynamic explanation. Attitudes regarding blaming and harmfulness of the alcohol dependent patients were increased in the neurobiological and sociodynamic group compared to the un-exposed control group.
Information regarding possible causalities regarding the development of alcohol dependence is associated with more negative attitudes towards alcohol dependent patients in the questioned students compared to unexposed controls. This may be reasoned by the recognition of alcohol dependence as a manifestation of mental illness and the subsequent inclusion of the alcohol dependent patients in the prejudices and acts of discrimination commonly leveled against the mentally ill. Therefore, multimodal interventions rather than medicinal information seem to be necessary in order to decrease stigmatization of the alcohol dependent patients.
Natural speech perception relies on both, auditory and visual information. Both sensory channels provide redundant and complementary information, such that speech perception is enhanced in healthy subjects, when both information channels are present.
Patients with schizophrenia have been reported to have problems regarding this audiovisual integration process, but little is known about which neural processes are altered.
In this study we investigated functional connectivity of Broca’s area in patients with schizophrenia.
Functional magnetic resonance imaging (fMRI) was performed in 15 schizophrenia patients and 15 healthy controls to study functional connectivity of Broca’s area during perception of videos of bisyllabic German nouns, in which audio and video either matched (congruent condition) or die not match (incongruent; e.g. video = hotel, audio = island).
There were differences in connectivity between experimental groups and between conditions. Broca’s area of the patient group showed connections to more brain areas than the control group. This difference was more prominent in the incongruent condition, for which only one connection between Broca's area and the supplementary motor area was found in control participants, whereas patients showed connections to 8 widely distributed brain areas.
The findings imply that audiovisual integration problems in schizophrenia result from maladaptive connectivity of Broca's area in particular when confronted with incongruent stimuli and are discussed in light of recent audio visual speech models.
The clinical observation suggests a relation between alcoholism and dysregulation of the hypothalamus-pituitary-gonadal hormone axis. Chronic alcohol abuse leads to hypogonadism and sexual dysfunction. Testosterone and the genetics of the androgen receptor [AR] are related to impulsivity as well as appetite/hunger, both associated with addiction.
This study investigated whether the length of a CAG trinucleotide repeat within the coding region of the AR is associated with alcoholism in general and whether it is linked to craving during withdrawal. Moreover, we concentrated on finding possible mediators of the observed effects.
We included 112 male inpatients who were admitted for detoxification treatment and who were compared to 50 age-matched controls. To measure the extent of craving we used the Obsessive Compulsive Drinking Scale (OCDS) on the day of hospital admission. For laboratory analysis we used whole blood (genetics) and serum (protein quantification).
The group of patients (21.6 ± 3.7 repeats) did not differ significantly from the control group (21.3 ± 3.3 repeats, p = 0.632) in terms of the number of CAG repeats. We found a significant negative correlation for the AR repeat length regarding OCDS-to (R2 = 0.053, p = 0.016) and OCDS-obs (R2 = 0.058, p = 0.011). Carrying out a path analysis of the mediating effect of leptin on the association between the number of CAG repeats of the AR and alcohol craving we found that direct effects (r = −0.144) accounted for 60% and indirect leptin-mediated effects (r = −0.096) for 40% of the total effect.
Today, the impact of the sexual hormone axis seems to be underestimated in alcoholism.
Many patients with major depressive disorder fail to achieve remission with standard antidepressant therapy. Current options for the management of treatment resistant depression (TRD) comprise dose optimization, switching within or between drug classes, augmenting with other drugs and combination strategies. However, the application of combination treatment may be limited by adverse side effects.
From February 2010 to February 2011, twelve inpatients with TRD were retrospectively identified as being treated with a combination of agomelatine and bupropion after discontinuation of former antidepressant treatment. Mean doses of agomelatine at the end of treatment were 47.9 ± 7.2 mg/d, and bupropion 325 ± 86.6 mg/d. Intensity of depressive symptoms was routinely assessed using Beck's Depression Inventory-2. Response was defined as decrease of BDI sum score by 50%, and remission as BDI sum score below 13. Metabolic parameters and adverse side effects were routinely measured. Statistical analysis was performed using paired t-test and repeated measurements ANOVA with degree of TRD as covariate, and unpaired t-test for gender comparisons.
Eight patients showed response, and seven reached remission after 6–8 weeks of inpatient treatment. This effect was independent of the degree of TRD.
How to continue antidepressive treatment after an initially unsuccessful trial is a vital question. However, guidance as to which option is to be favoured remains limited. In particular, the use of antidepressant combinations to address TRD is understudied. We have shown that combination treatment with agomelatine/bupropion in TRD may lead to significant symptom relief. Future randomized controlled trials are needed to confirm our results.
Changes in DNA-methylation patterns in alcohol-dependent patients have been described in various studies. However, epigenetic regulation of genes responsible for the ethanol metabolism has not been in the focus of recent research.
Aim of our study was to evaluate changes in DNA-methylation of the aldehyde dehydrogenase 2 (ALDH2) in respect to genetic variants (rs886205 ALDH2-SNP) in blood samples of alcohol-dependent patients compared with healthy controls.
During an inpatients detoxification treatment we draw blood samples from 82 alcohol-dependent, male patients on day 1, day 7 and day 14. Bisulfite-treated DNA was subjected to methylation analysis via sequencing. Findings of the alcohol-dependent group were compared with results of a healthy control group (N=34)
Our results show decreasing methylation levels of a repressive ALDH2 promoter fragment to control levels only in homozygous A-allele patients of the rs886205 SNP.
Findings of this study reveal a specific genetic-epigenetic interaction in ALDH2 regulation which may have crucial importance for the understanding of epigenetic regulation of ethanol metabolism in humans
The prevalence of many diseases in pigs displays seasonal distributions. Despite growing concerns about the impacts of climate change, we do not yet have a good understanding of the role that weather factors play in explaining such seasonal patterns. In this study, national and county-level aggregated abattoir inspection data were assessed for England and Wales during 2010–2015. Seasonally-adjusted relationships were characterised between weekly ambient maximum temperature and the prevalence of both respiratory conditions and tail biting detected at slaughter. The prevalence of respiratory conditions showed cyclical annual patterns with peaks in the summer months and troughs in the winter months each year. However, there were no obvious associations with either high or low temperatures. The prevalence of tail biting generally increased as temperatures decreased, but associations were not supported by statistical evidence: across all counties there was a relative risk of 1.028 (95% CI 0.776–1.363) for every 1 °C fall in temperature. Whilst the seasonal patterns observed in this study are similar to those reported in previous studies, the lack of statistical evidence for an explicit association with ambient temperature may possibly be explained by the lack of information on date of disease onset. There is also the possibility that other time-varying factors not investigated here may be driving some of the seasonal patterns.
To explore the formal and informal ways in which different actors involved in shaping trade agreements pursue their interests and understand the interactions with nutrition, in order to improve coherence between trade and nutrition policy goals.
The paper draws on empirical evidence from Australian key informant interviews that explore the underlying political dimensions of trade agreements that act as barriers or facilitators to getting nutrition objectives on trade agendas.
Countries experiencing greater availability and access to diets full of energy-dense and nutrient-poor foods through increased imports, greater foreign direct investment and increasing constraints on national health policy space as a result of trade agreements.
Interviews took place with Australian government officials, industry, public-interest non-government organizations and academics.
The analysis reveals the formal and informal mechanisms and structures that different policy actors use both inside and outside trade negotiations to pursue their interests. The analysis also identifies the discourses used by the different actors, as they attempt to influence trade agreements in ways that support or undermine nutrition-related goals.
Moving forward requires policy makers, researchers and health advocates to use various strategies including: reframing the role of trade agreements to include health outcomes; reforming the process to allow greater access and voice to health arguments and stakeholders; establishing cross-government partners through accountable committees; and building circles of consensus and coalitions of sympathetic public-interest actors.
Marriages between the aristocratic elite played an important role in the exchange of fashion at early modern European courts. Because bridal couples usually came from different regions or countries, different styles of clothing came into contact at the wedding celebration as well as afterwards, when the bride started living at her husband’s court. Focussing on princely German courts in the fifteenth and sixteenth centuries, this paper shows how noble women took their natal dress with them to their marital court and how the court reacted to their foreign style. By analysing the dress practices of noble women, this essay looks into the political potentials of dress and the shaping of identities of the female elite at German courts.
In the late Middle Ages, kinship ties within the European aristocracy were of major importance for cultural exchange processes at princely courts. A relatively dense network of marriage relationships formed the basis for a wide range of different contacts; and the increasing mobility towards the end of the Middle Ages intensified this even further. These relationships also favoured the exchange and communication of princely fashions between different regions and countries. During the subsequent transition from the Middle Ages to the early modern period by the end of the fifteenth and the beginning of the sixteenth century, princely dress practices were not just determined socially but also and above all culturally. Anchored in specific life worlds, they maintained not only social position, lineage, and/or family status, but also specific, although not clearly circumscribed, geographical spaces. Contemporaries already registered differences between domestic and foreign princely dress very precisely and assumed that there were several simultaneously coexisting, spatially linked fashions. Envoys and emissaries who helped communicate news and cultivate social contacts reported on dress customs at other courts, and they frequently took robes or fabrics home as presents. Aristocrats receiving their training at several different courts also spread knowledge about foreign dress styles. However, what were likely even more significant for the exchange of fashions were the personal meetings between the aristocrats themselves that occurred – frequently on the basis of existing familial ties – within, for example, the framework of court feasts, longer stays for educational and training purposes, and political negotiations or visits.
Maximising synergies and minimising conflicts (i.e. building policy coherence) between trade and nutrition policy is an important objective. One understudied driver of policy coherence is the alignment in the frames, discourses and values of actors involved in the respective sectors. In the present analysis, we aim to understand how such actors interpret (i.e. ‘frame’) nutrition and the implications for building trade–nutrition policy coherence.
We adopted a qualitative single case study design, drawing on key informant interviews with those involved in trade policy.
We focused on the Australian trade policy sub-system, which has historically emphasised achieving market growth and export opportunities for Australian food producers.
Nineteen key informants involved in trade policy spanning the government, civil society, business and academic sectors.
Nutrition had low ‘salience’ in Australian trade policy for several reasons. First, it was not a domestic political priority in Australia nor among its trading partners; few advocacy groups were advocating for nutrition in trade policy. Second, a ‘productivist’ policy paradigm in the food and trade policy sectors strongly emphasised market growth, export opportunities and deregulation over nutrition and other social objectives. Third, few opportunities existed for health advocates to influence trade policy, largely because of limited consultation processes. Fourth, the complexity of nutrition and its inter-linkages with trade presented difficulties for developing a ‘broader discourse’ for engaging the public and political leaders on the topic.
Overcoming these ‘ideational challenges’ is likely to be important to building greater coherence between trade and nutrition policy going forward.
Latent stochastic blockmodels are flexible statistical models that are widely used in social network analysis. In recent years, efforts have been made to extend these models to temporal dynamic networks, whereby the connections between nodes are observed at a number of different times. In this paper, we propose a new Bayesian framework to characterize the construction of connections. We rely on a Markovian property to describe the evolution of nodes' cluster memberships over time. We recast the problem of clustering the nodes of the network into a model-based context, showing that the integrated completed likelihood can be evaluated analytically for a number of likelihood models. Then, we propose a scalable greedy algorithm to maximize this quantity, thereby estimating both the optimal partition and the ideal number of groups in a single inferential framework. Finally, we propose applications of our methodology to both real and artificial datasets.
The current short communication aimed to provide a new conceptualisation of the policy drivers of inequities in healthy eating and to make a call to action to begin populating this framework with evidence of actions that can be taken to reduce the inequities in healthy eating.
The Healthy and Equitable Eating (HE2) Framework derives from a systems-based analytical approach involving expert workshops.
Academics, government officials and non-government organisations in Australia.
The HE2 Framework extends previous conceptualisations of policy responses to healthy eating to include the social determinants of healthy eating and its social distribution, encompassing policy areas including housing, social protection, employment, education, transport, urban planning, plus the food system and environment.
As the burden of non-communicable diseases continues to grow globally, it is important that governments, practitioners and researchers focus attention on the development and implementation of policies beyond the food system and environment that can address the social determinants of inequities in healthy eating.
The study aimed to investigate severe hair loss related to psychotropic drugs (PDs) by using data from the drug safety programme Arzneimittelsicherheit in der Psychiatrie (AMSP).
Data on PD utilization and reports of severe PD-related hair loss were collected in 83 psychiatric hospitals in Austria, Germany and Switzerland during the period 1993–2013.
Out of 432, 215 patients under surveillance, 404, 009 patients were treated with PDs for the main indications of depression, schizophrenic disorder, neurosis, mania, and organic psychosis. Severe hair loss related to PD treatment was reported in 43 cases (0.01%). The rates of hair loss under antipsychotic drugs were slightly lower than the mean rates of all PDs and antidepressant drugs. Valproic acid was related to the highest risk. In 6 of the 43 cases, hair loss was imputed to multiple drugs, with 4 cases imputed to double drug combinations and 2 cases to triple combinations. Rates of severe hair loss under valproic acid (VPA) and lithium salts were distinctly lower as compared with the overall rates reported in literature. Severe hair loss under PD treatment was reported significantly more often in female patients than in male patients (p < 0.01).
The rate of severe PD-related hair loss was very low in the present survey. The large number of patients included in this multicentre study allows for assessment and comparison of hair loss rates related to different PDs and groups of PDs and provides new and supplementary information on PD-related hair loss.
In general, a functioning liability and insurance framework should ensure an adequate level of third party claimant protection and a reasonable and adequate final allocation of liability costs for the involved parties. This research examines whether the liability and insurance framework resulting from the amendment to German Road Traffic Act meets these two central objectives. The article shows that a reasonable and adequate allocation of liability costs is inhibited because of several barriers that hinder the shift of liability costs from the owner of the vehicle to the manufacturer. In particular, it is highly dependent on the practical application of subrogation claims. The ability and the motivation of motor insurers to conduct subrogation claims could be negatively affected because of a lack of required technical and engineering know-how and because a market-wide conduction of subrogation claims would erode the business model of motor insurance. This article proposes changes to the current framework particularly by removing specific exclusions of product liability and by easing the burden of proof of a product defect.
OBJECTIVES/SPECIFIC AIMS: The aim of this study was to assess the ultra-dose Na18F dPET protocol feasibility for skeleton imaging in a canine model with reduced radiation dose and preserved quantitative characteristics. We hypothesized that administering an ultra-low Na18F dose would provide suitable image quality while reducing subject’s exposure to radiation. METHODS/STUDY POPULATION: In total, 13 adult male beagles [weight (kg) mean±SD; 14.3±2.2] were scanned. The dogs were administered 3 different Na18F doses: 3 (standard dose/SD), 1 (low dose/LD), and 0.05 (ultra-low dose/ULD) mCi. Imaging started ≃45 minutes post injection for ≃ 33 minute total acquisition time. Covering the whole body, 11 bed positions, acquiring 120 (3 mCi) and 180 (1, 0.05 mCi) seconds per bed position. All imaging was performed on a digital photon counting system (Philips Vereos, pre-commercial release). PET list mode data were reconstructed using Time-of-flight with 4, 2, and 1 mm3 voxel volumes. Point spread function, and Gaussian filtering were applied. Two experienced blinded readers evaluated image sets overall quality, tissue characterization, and quality of background in the whole body skeleton. Three-dimensional (3D) regions of interest (ROI) were traced over the distal femur, first lumbar vertebra, and a portion of the liver, recording standard uptake values (SUVmax and SUVmean). RESULTS/ANTICIPATED RESULTS: All the scans and reconstructions were successfully completed in all subjects. Decreasing Na18F dose from the standard dose (3 mCi) to the ultra-low dose/ULDO (0.05 mCi), demonstrated acceptable image quality and quantification. Ultra-low dose Na18F SUVmean values for the 3D ROIs reported (mean±SD) 2.6±0.7, 2.5±1.1, 9±1.6, and 0.6±0.3 from the right and left distal femur, first lumbar vertebra, and a portion of the liver, respectively. When compared the SD with the LD and ULD, dPET demonstrated acceptable image quality and definition for qualitative overall assessment. This was also found for the overall quantitative ROI assessment of the healthy canine skeletons. DISCUSSION/SIGNIFICANCE OF IMPACT: Ultra-low dose Na18F at a level of 50 μCi for a 14 kg canine appears to be diagnostically feasible and a robust option to reduce (60-fold) radiotracer doses in a translational animal model using a dPET system. Furthermore, it allows us to move preclinical nuclear medicine imaging forward with substantial reduced exposure levels while preserving image quality. Both visual and quantitative results indicate that the standard-dose bone Na18F dPET can be decreased with a satisfactory diagnostic image quality. Ultra-low Na18F dose is indeed important for younger populations, control patients, and nononcological diseases/conditions. Favorable pharmacokinetics of Na18F (such as high bone uptake, minimal binding to serum proteins, rapid single-pass extraction, and fast clearance from the soft tissues) in addition to the technological capabilities of dPET/CT demonstrated feasibility enabling dose reduction strategies. Ultra-low dose has diagnostic reproducibility and lower radiation burden compared with higher fixed dose techniques in current available guidelines [Society of Nuclear Medicine and Molecular Imaging; SNMMI (5–10 mCi)]. Na18F dPET/CT provides higher sensitivity and diagnostic accuracy, which enables high-quality images with lower tracer activity in this translational animal model. Future research will apply the same methodology to other anatomical targets as well as to the use of different tracers. Preclinical nuclear medicine imaging using ultra-low tracer doses, demonstrated the potential to obtain reasonable quality images and diminishing radiation surveillance in accordance with as low as reasonably achievable tracer levels.
The latent position cluster model is a popular model for the statistical analysis of network data. This model assumes that there is an underlying latent space in which the actors follow a finite mixture distribution. Moreover, actors which are close in this latent space are more likely to be tied by an edge. This is an appealing approach since it allows the model to cluster actors which consequently provides the practitioner with useful qualitative information. However, exploring the uncertainty in the number of underlying latent components in the mixture distribution is a complex task. The current state-of-the-art is to use an approximate form of BIC for this purpose, where an approximation of the log-likelihood is used instead of the true log-likelihood which is unavailable. The main contribution of this paper is to show that through the use of conjugate prior distributions, it is possible to analytically integrate out almost all of the model parameters, leaving a posterior distribution which depends on the allocation vector of the mixture model. This enables posterior inference over the number of components in the latent mixture distribution without using trans-dimensional MCMC algorithms such as reversible jump MCMC. Our approach is compared with the state-of-the-art latentnet (Krivitsky & Handcock, 2015) and VBLPCM (Salter-Townshend & Murphy, 2013) packages.
ABSTRACT. The sea was profoundly important in medieval England. Anglo-Saxon seaborne colonisation led to the development of the nation, and the later Norman Conquest drew England into what proved to be a fatal involvement in the politics of France. English maritime technology belonged to the north-European tradition, and sea trade permeated the nation and stimulated urban development. However, until the 15th century the country's trade was mostly dominated by foreign merchants and ships. English kings were able make effective use of the country's shipping in various wars between the 13th and 15th centuries, though by the late 15th century England was in decline as a naval and economic seapower.
RÉSUMÉ. La mer était très importante dans l'Angleterre médiévale. La colonisation maritime des Anglo-Saxons a conduit au développement de la nation, et la conquête normande plus tard a attiré l'Angleterre dans ce qui s'est avéré être une implication mortelle dans la politique de la France. La technologie maritime anglaise appartenait à la tradition nord-européenne et le commerce maritime imprégnait la nation et stimulait le développement urbain. Cependant, jusqu'au XVe siècle le commerce du pays était principalement dominé par des marchands et des navires étrangers. Les rois anglais ont été en mesure d'utiliser efficacement le transport maritime du pays dans les différentes guerres entre le XIIIe et le XVe siècle, bien qu'à la fin du XVe siècle, l'Angleterre fût en déclin comme puissance maritime navale et économique.
Quite apart from its direct physical effects, the sea has always had a powerful impact on the history of island nations. In this paper ‘the sea’ is taken to mean ‘the uses that people have made of the sea’. In this sense, the medieval English nation owed its origin to the sea, and the country's subsequent development was deeply affected by it.
AN HISTORICAL OVERVIEW
One of the key attributes of a ship is mobility, and this attribute made medieval Britain vulnerable to the ships of invaders and colonisers. In the 5th and 6th centuries those incomers were the pagan Angles, Saxons and Jutes, who landed on the eastern and southern shores of the former Roman province of Britannia.