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A common feature of successful ancient states was the role of elites in maintaining and regulating socioeconomic structures and, in particular, emphasising their own social difference. The Wari (AD 600–1000) are considered the earliest expansive state in South America, and excavations have demonstrated the rich variety of exotic goods imported from across the region into the polity's heartland. Here, the authors argue that the importation of raw materials, plants, animals and people from distant regions was crucial for defining and sustaining Wari social differentiation and ideology. They emphasise the importance of studying material provenance and their archaeological contexts in order to understand the role of exotic goods in legitimising ruling groups in ancient states.
Recently, artificial intelligence-powered devices have been put forward as potentially powerful tools for the improvement of mental healthcare. An important question is how these devices impact the physician-patient interaction.
Aifred is an artificial intelligence-powered clinical decision support system (CDSS) for the treatment of major depression. Here, we explore the use of a simulation centre environment in evaluating the usability of Aifred, particularly its impact on the physician–patient interaction.
Twenty psychiatry and family medicine attending staff and residents were recruited to complete a 2.5-h study at a clinical interaction simulation centre with standardised patients. Each physician had the option of using the CDSS to inform their treatment choice in three 10-min clinical scenarios with standardised patients portraying mild, moderate and severe episodes of major depression. Feasibility and acceptability data were collected through self-report questionnaires, scenario observations, interviews and standardised patient feedback.
All 20 participants completed the study. Initial results indicate that the tool was acceptable to clinicians and feasible for use during clinical encounters. Clinicians indicated a willingness to use the tool in real clinical practice, a significant degree of trust in the system's predictions to assist with treatment selection, and reported that the tool helped increase patient understanding of and trust in treatment. The simulation environment allowed for the evaluation of the tool's impact on the physician–patient interaction.
The simulation centre allowed for direct observations of clinician use and impact of the tool on the clinician–patient interaction before clinical studies. It may therefore offer a useful and important environment in the early testing of new technological tools. The present results will inform further tool development and clinician training materials.
The goal of this chapter is to provide an overview of how environmental sociologists can use spatial data and analytical techniques to advance environmental sociology. This chapter begins with the premise that individuals are embedded within specific environmental contexts and, consequently, spatial data and analyses are tools that help identify environmental forces relevant to human society. We assert that the environment is inherently spatial, and that the explicit consideration of one location relative to another is a distinguishing feature of “spatial” studies. This chapter begins with an overview of general definitions, and foundational theoretical and methodological concepts. We then highlight compelling spatially-explicit work in the environmental sociology literature on migration, land use, environmental justice, sustainable livelihoods, and poverty. Finally, we conclude with a discussion of future possibilities to enhance theories on human–environment interactions by incorporating spatial data. Our overarching aim is to elucidate the relational nature between locations, the environment, and human-environment processes in order to encourage the use of spatial tools and to promote new ways of thinking spatially.
Inflammation may contribute to the high prevalence of depressive symptoms seen in lung cancer. “Sickness behavior” is a cluster of symptoms induced by inflammation that are similar but distinct from depressive symptoms. The Sickness Behavior Inventory-Revised (SBI-R) was developed to measure sickness behavior. We hypothesized that the SBI-R would demonstrate adequate psychometric properties in association with inflammation.
Participants with stage IV lung cancer (n = 92) were evaluated for sickness behavior using the SBI-R. Concomitant assessments were made of depression (Patient Hospital Questionniare-9, Hospital Anxiety and Depression Scale) and inflammation [C-reactive protein (CRP)]. Classical test theory (CTT) was applied and multivariate models were created to explain SBI-R associations with depression and inflammation. Factor Analysis was also used to identify the underlying factor structure of the hypothesized construct of sickness behavior. A longitudinal analysis was conducted for a subset of participants.
The sample mean for the 12-item SBI-R was 8.3 (6.7) with a range from 0 to 33. The SBI-R demonstrated adequate internal consistency with a Cronbach's coefficient of 0.85, which did not increase by more than 0.01 with any single-item removal. This analysis examined factor loadings onto a single factor extracted using the principle components method. Eleven items had factor loadings that exceeded 0.40. SBI-R total scores were significantly correlated with depressive symptoms (r = 0.78, p < 0.001) and CRP (r = 0.47, p < 0.001). Multivariate analyses revealed that inflammation and depressive symptoms explained 67% of SBI-R variance.
Significance of results
The SBI-R demonstrated adequate reliability and construct validity in this patient population with metastatic lung cancer. The observed findings suggest that the SBI-R can meaningfully capture the presence of sickness behavior and may facilitate a greater understanding of inflammatory depression.
It is trite law that international arbitration is subject to control. When two parties agree to arbitrate a dispute, the resulting arbitral award will be recognized as producing legal effects only if it fulfills the conditions set forth in the applicable arbitration framework. This is due to the dual foundation of arbitration in party autonomy on the one hand and the applicable arbitration framework on the other.1 If one turns to the question of who is tasked to exercise this control, the answer is not straightforward. At first glance, it appears as if national courts are the sole guardians to watch over arbitral awards. This view reflects a public–private divide between arbitral tribunals who as private actors render an arbitral award, which is then subject to control by a national court as a public actor.
Background:Staphylococcus aureus–colonized hospitalized patients are at risk for invasive infection and can transmit S. aureus to other patients in the absence of symptoms. Infection isolation precautions do not reduce the risk of infection in colonized patients and are untenable in health systems with high rates of S. aureus colonization. Objective: We implemented an inpatient S. aureus screening and targeted decolonization program across hospital campuses to reduce transmission and invasive infection. We screen and decolonize for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) because MSSA makes up more than half of all S. aureus isolated from clinical cultures in our health system. Methods: All medicine, pediatrics, and transplant patients receive S. aureus nares culture at admission and upon change in level of care for medicine, and at admission and weekly for pediatrics and transplant patients. All S. aureus–colonized patients receive decolonization with nasal mupirocin ointment and chlorhexidine baths. Two implementation frameworks guide our processes for S. aureus screening and decolonization: the Consolidated Framework for Implementation Research, to evaluate factors affecting implementation at different levels of the health system, and the Dynamic Sustainability Framework, to account for iterative changes as the hospital setting and patient population change over time. Implementation interventions focus on education of patients and bedside nurses who perform S. aureus screening and decolonization; utilization of the electronic health record to identify patients for screening and/or decolonization and avoid human error; and introduction of a clinical nurse specialist to oversee the program and to provide iterative feedback. Results: At baseline, 21% of patients had S. aureus colonization, 20% of which was MRSA, and the MRSA bloodstream infection rate was 0.06 per 1,000 patient days. After program implementation, there was no change in S. aureus colonization and the MRSA bloodstream infection rate fell to 0.04 per 1,000 patient days. Screening compliance improved from 39% (N = 1,805) of eligible patients in the 6-month period before the introduction of the clinical nurse specialist to 52% (N = 2,024) after the introduction of the clinical nurse specialist. In the same periods, decolonization increased from 18.6% to 41% of eligible patients. Conclusions: We used 2 implementation frameworks to design our S. aureus screening and decolonization program and to make iterative changes to the program as it evolved to include new patient populations and different hospital settings. This resulted in a large-scale, sustainable, health system program for S. aureus control that avoids reliance on infection isolation precautions.
Background: Contaminated surfaces within patient rooms and on shared equipment is a major driver of healthcare-acquired infections (HAIs). The emergence of Candida auris in the New York City metropolitan area, a multidrug-resistant fungus with extended environmental viability, has made a standardized assessment of cleaning protocols even more urgent for our multihospital academic health system. We therefore sought to create an environmental surveillance protocol to detect C. auris and to assess patient room contamination after discharge cleaning by different chemicals and methods, including touch-free application using an electrostatic sprayer. Surfaces disinfected using touch-free methods may not appear disinfected when assessed by fluorescent tracer dye or ATP bioluminescent assay. Methods: We focused on surfaces within the patient zone which are touched by the patient or healthcare personnel prior to contact with the patient. Our protocol sampled the over-bed table, call button, oxygen meter, privacy curtain, and bed frame using nylon-flocked swabs dipped in nonbacteriostatic sterile saline. We swabbed a 36-cm2 surface area on each sample location shortly after the room was disinfected, immediately inoculated the swab on a blood agar 5% TSA plate, and then incubated the plate for 24 hours at 36°C. The contamination with common environmental bacteria was calculated as CFU per plate over swabbed surface area and a cutoff of 2.5 CFU/cm2 was used to determine whether a surface passed inspection. Limited data exist on acceptable microbial limits for healthcare settings, but the aforementioned cutoff has been used in food preparation. Results: Over a year-long period, terminal cleaning had an overall fail rate of 6.5% for 413 surfaces swabbed. We used the protocol to compare the normal application of either peracetic acid/hydrogen peroxide or bleach using microfiber cloths to a new method using sodium dichloroisocyanurate (NaDCC) applied with microfiber cloths and electrostatic sprayers. The normal protocol had a fail rate of 9%, and NaDCC had a failure rate of 2.5%. The oxygen meter had the highest normal method failure rate (18.2%), whereas the curtain had the highest NaDCC method failure rate (11%). In addition, we swabbed 7 rooms previously occupied by C. auris–colonized patients for C. auris contamination of environmental surfaces, including the mobile medical equipment of the 4 patient care units that contained these rooms. We did not find any C. auris, and we continue data collection. Conclusions: A systematic environmental surveillance system is critical for healthcare systems to assess touch-free disinfection and identify MDRO contamination of surfaces.
Background: Whole-genome sequencing (WGS) has a high discriminatory power in confirming outbreaks. Outbreak investigation models that categorize the possibility of an outbreak based on the degree of genetic relatedness of isolates are highly dependent on the single-nucleotide polymorphism (SNP) threshold used. Methods: NYU Langone Medical center is a 725-bed academic center that has implemented WGS of methicillin-resistant Staphylococcus aureus (MRSA) isolates since 2016. Patients admitted to a medical or intensive care unit were screened on admission and transfer. The first surveillance and clinical MRSA isolate during each hospitalization was sequenced. We conducted a retrospective analysis to identify strong epidemiologic links among patients involved in genetically related clusters. We used different SNP thresholds to define genetic relatedness to identify the optimal threshold that should prompt an outbreak investigation. We considered strong hospital epidemiologic links sharing the same room or unit or having resided in the same room or unit within 7 days. A pairwise analysis was conducted to compare the epidemiologic links among patients involved in genetically related clusters. Results: Among 1,070 isolates, our analysis focused on 777 belonging to USA100 and USA300 clones. For USA100 isolates, we identified 8, 14, and 20 clusters comprising of 16, 29, and 42 patients when the threshold for genetic relatedness was set at 20, 40, and 60 SNP differences, respectively. Patients identified in a cluster yielded a strong hospital epidemiologic link in 62.5%, 87.5%, and 91.7% of cases (Fig. 1). For USA300 isolates, SNP differences of 10, 20, and 30 were used, identifying 20, 34, and 40 clusters of 43, 79, and 127 patients. The expansion of the threshold from 10 to 30 resulted in a decrease of the percentage of pairwise analyses with a strong hospital epidemiologic link from 57.7% to 13.6% by increasing 13-fold the number of analyses that were conducted to identify only 3 times more cases with strong epidemiologic links (Fig. 2). Conclusions: The results of our study indicate that SNPs thresholds determined by intrapatient variability of MRSA isolates might need to be tailored to the individual setting to guide infection control interventions because optimal thresholds might vary depending on characteristics of the population, MRSA isolates, and screening practices. Establishing conservative thresholds might allow the identification and quantification over time of the locations (eg, rooms or units) where transmission is occurring as well as the investigation of the clusters without strong epidemiologic links that might be valuable in elucidating unrecognized routes of transmission.
Diseases of the nervous system are an enormous burden to patients and society. Brain computer interfaces (BCIs) aim to improve or even eliminate the handicaps associated with these diseases by linking the brain and a computer via scalp, subdural, or intracortical electrodes. The transfer of information to and from the brain can be used to restore function. This chapter starts with a brief introduction to the recent history of BCIs, followed by the main topic of this chapter: the ethical challenges associated with BCIs. The ethical issues to be discussed include agency and identity, privacy, security, and informed consent. The management of patient and family expectations and balancing the risks and benefits of BCIs are also explored. Establishing the efficacy of BCIs and the challenges related to the principles of justice are also discussed. BCIs could potentially be used to enhance normal function, and this raises many ethical questions. In the last part of this chapter, future directions of BCIs including potential technical advances such as connectivity of the brain to ‘the cloud’ and ‘brain nets’ will be outlined. The challenges outlined in this chapter need to be addressed, both by those responsible for the technical development of BCIs, but also by neurosurgeons, policy makers, and law makers.
There has been a resurgence in the practice of psychosurgery in the last decade primarily for depression and obsessive compulsive disorder. This is due to the application of deep brain stimulation (which has largely replaced lesioning) and to a greater understanding of the imaging correlates of mental illness. Psychosurgery is expanding well beyond these indications. Many ethical challenges arise, including informed consent, establishing the efficacy of these procedures from the literature and in the design of new studies, the harm versus benefit ratio, and the role of institutional and governmental regulatory control over psychosurgery. Psychosurgery remains experimental or at least investigational and the ethical considerations should be of prime importance for any practitioner undertaking this surgery. We propose eighteen principles as a basis for a regulatory framework of psychosurgery. Neurosurgeons who perform psychosurgery have an immense responsibility to guard against a repeat of the failures of the past.
Surgical innovation is a major driver of progress in neurosurgery. While clinical ethics and research ethics are well-defined, there is limited knowledge about sound ethics of surgical innovation. Here, we discuss different ethical aspects of innovation, including oversight, conflicts of interest, the surgical learning curve, introducing surgical devices, informed consent, and vulnerable patient populations. A robust ethical framework can empower surgeons to innovate in a way that both protects patients and advances the neurosurgical discipline.
Economic inequality in the United States has reached heights unscaled since before the Great Depression. Today the top 1 percent wealthiest Americans hold nearly 40 percent of the country’s wealth (up from about 20 percent in 1980) and earn over one-fifth of all income (up from about 10 percent in 1980). The doubling of top-end wealth and income inequality has coincided with economic stagnation for millions of American workers, especially men, and especially men without a college education. These troubling trends led President Obama to announce that rising inequality and declining mobility are “the defining challenge[s] of our time.”
An employer willing to invest resources and hire a competent representative can avoid a first contract in almost every case. Experience suggests that obtaining a first contract occurs in substantially less than 50 percent of the circumstances where unions win representation elections. I explore in this chapter how the law allows employers to avoid a first contract.
Ever since Donald Trump announced his candidacy for the US presidency in June 2015, journalists, scholars, and other commentators in the United States have attempted to explain his political success with the aid of historical analogies. In so doing, they have sparked a wider debate about whether the Nazi past helps to make sense of the US present. One group in the debate has contended that Trump's ascent bears a worrisome resemblance to interwar European fascism, especially the National Socialist movement of Adolf Hitler. By contrast, a second group has rejected this comparison and sought analogies for Trump in other historical figures from European and US history. This article surveys the course, and assesses the results, of the debate from its origins up to the present day. It shows that historians of Germany have played a prominent role in helping to make sense of Trump, but notes that their use of Nazi analogies may be distorting, rather than deepening, our understanding of contemporary political trends. By examining the merits and drawbacks of Nazi analogies in present-day popular discourse, the article recommends that scholars draw on both the German and American historical experience in order to best assess the United States's present political movement.
Today’s parties are hollow parties, neither organizationally robust beyond their roles raising money nor meaningfully felt as a real, tangible presence in the lives of voters or in the work of engaged activists. The parties have become tarred with elements of polarization that the public most dislikes—from the screaming antagonism to the grubby money chase. More than any positive affinity or party spirit, fear and loathing of the other side fuels parties and structures politics for most voters. Party identification drives American politics—but party loyalty, in the older sense of the term, has atrophied. Even the activists who do so much to shape modern politics typically labor outside of the parties, drawn to ideologically tinged “para-party” groups such as MoveOn.org on the left or the Koch-backed Americans for Prosperity on the right. The parties offer clear choices but get no credit. Our new Party Period features a nationalized clash of ideology and interests but parties that are weakly legitimized and hollowed out.
This essay tells one strand of a story in which philosophies of happiness and arts of love mixed and mingled— in both philosophical and literary traditions. The very idea of a philosophical art of love leads us back to Ovid, whose Ars amatoria (Art of Love, composed c. 2 CE) plays upon a vigorous tradition of instruction about love (“erotodidaxis”) already existing across the discourses of elegy, philosophy, drama and erotic treatise. As scholars have long noted, in Ovid's hands— and with his signature irony— erotic instruction engages in political and ethical questions as much as amatory matters. In contrast to the genre of the love elegy, Ovid's Ars amatoria does not create an opposition between love and civil life, but rather “sets up love as a serious ethical concern” (Green 2006, 7). Ovid portrays sexual pleasure as the root of human civilization and the height of fulfillment— the highest reward for self- knowledge. The Latin and vernacular literature of Western Europe in the later Middle Ages inherited Ovid's version of the erotodidactic tradition, and this essay explores some medieval transformations of the “art of love” as they relate to discourses of happiness. Ovid's Ars amatoria itself was widely read, commented upon and variously adapted and translated into Western European vernaculars (Minnis 2001, 35–81). I am most interested here in the absorption of Ovidian erotodidaxis into philosophical discourse.
A striking example of such absorption occurs in the twelfth century, when Andreas Capellanus wrote a widely circulated Latin treatise, De amore, clearly modeled to some extent on Ovid's text, with the narrator adopting the pose of the praeceptor amoris. The De amore— a treatise partly in the form of a scholastic quaestio dedicated to another man on the subject of heterosexual love and possibly written at the request of Marie de Champagne in the 1180s— had wide enough (and controversial enough) circulation to be included in a list of condemned texts by the bishop of Paris in 1277; Andreas's work is one piece of evidence among many that the genre of the “art of love” had already been assimilated to the forms of scholastic philosophy.