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Gender in socio-legal teaching and research in Germany is a story of impediments, hindrances, and of singleperson initiatives—my personal history being a part of this. But it is also a story of influences upon the impulse and inspiration to undertake socio-legal work. My Article is therefore influenced by (feminist) standpoint theory (Harding 1991). Germany has had a very conservative family culture and, over the past decades, many of the legal regulations that infringed upon women have had to be adapted, in what was quite a tedious political process, to comply with the German Constitution’s gender equality clause. Only in the past decade has gender awareness in law faculties increased and gained acceptance, usually as a result of greater focus on diversity issues, and anti-discrimination legislation. Obstacles have resulted from a lack of cooperation between the actors in social sciences and law, as well as in academia and gender equality practice, and a lack of understanding between more conservative and more progressive women. Socio-legal research was, and is, needed to deliver empirical evidence and provide theoretical foundations for cultural and legal changes as societies progress towards gender equality. Socio-legal teaching is needed to alert lawyers to necessary change, to enable them to undertake informed critique, and to prepare them to act. There are, however, marked deficits in socio-legal teaching and research on gender. In spite of an increased political acceptance, gender equality is still mainly a women’s project.
Background: Infection prevention efforts are complex, and sustaining reductions is even more challenging. At the UNC Medical Center, multidisciplinary hospital-wide work groups implement quality improvement initiatives to prevent healthcare-associated infections. The first and most successful initiative has been our catheter-associated urinary tract infection (CAUTI) prevention effort, which started in 2014. The program led to initial dramatic reductions, with continued reductions in CAUTI rates each year since then. Methods: A multidisciplinary workgroup formed in 2014 developed an evidence-based CAUTI prevention bundle and partnered with the nursing staff in 2015–2016 to implement practice changes as part of our hospital’s quality improvement “Spread of Innovations” model. These changes included (1) creation of a 2-person catheter-insertion checklist; (2) insertion skills validation for all nursing staff and nursing assistants; (3) standardization of a maintenance protocol and subsequent education and skills validation with nurses and nurse assistants; and (4) peer audits of urinary catheter maintenance. Additional initiatives implemented over the past 5 years include (1) routine resident education on CAUTI prevention; (2) annual nurse competencies to reinforce skills around CAUTI prevention; (3) introduction of products (eg, PureWick) as alternatives to indwelling catheters; (4) diagnostic stewardship efforts; (5) revisions to the electronic medical record; and (6) efforts to encourage removal of unnecessary catheters such as the “nurse-driven conversation” and Trial of Void. Results: Our CAUTI rates decreased 65% from 2.94 per 1,000 catheter days in the baseline period of 2014 to 1.02 in 2018. In our ICUs (excluding the neonatal ICU), the rate dropped 75% from 4.30 in 2014 to 1.08 per 1,000 catheter days in 2018. Conclusions: We attribute our continued reductions and successful sustainment of low CAUTI rates to several factors. First, the use of a multidisciplinary team was critical to obtaining buy-in from key stakeholders including nursing, nurse assistants, physicians, pharmacists, performance improvement specialists, and administration. Second, continuation of the maintenance peer audits outside the initial project year has provided an important framework for this project, giving regular opportunities for frontline staff to evaluate patients’ catheter condition and to give feedback to colleagues or “just in time education.” These activities potentially prevent infections in real time. Third, with the many competing priorities demanding clinicians’ attention, it has been important for the CAUTI workgroup to continue to evaluate the problem, to determine where opportunities for improvement remain, and to tailor initiatives to meet those needs. In this way, new work can focus on priorities identified by staff, and CAUTI prevention initiatives remain relevant.
The current study aimed to investigate availability and placement of healthy and discretionary (less healthy) food in supermarkets in Victoria, Australia, and examine variation by supermarket chain and area-level socio-economic disadvantage.
Cross-sectional supermarket audit. Measures included: (i) proportion of shelf space (in square metres) allocated to selected healthy and discretionary food and beverages; (ii) proportion of end-of-aisle, checkout and island bin displays containing discretionary food and beverages and (iii) proportion of space within end-of-aisle, checkout and island bin displays devoted to discretionary food and beverages.
Metropolitan areas of Melbourne and Geelong, Australia. Assessment: June–July 2019.
Random sample of 104 stores, with equal numbers from each supermarket group (Coles, Woolworths, Aldi and Independent stores) within strata of area-level socio-economic position.
Proportion of shelf space devoted to selected discretionary foods was greater for Independent stores (72·7 %) compared with Woolworths (65·7 %), Coles (64·8 %) and Aldi (63·2 %) (all P < 0·001). Proportion of shelf space devoted to selected discretionary food for all Coles, Woolworths and Aldi stores was 9·7 % higher in the most compared with the least disadvantaged areas (P = 0·002). Across all stores, 90 % of staff-assisted checkout displays and 50 % of end-of-aisle displays included discretionary food. Aldi was less likely to feature discretionary food in end-of-aisle and checkout displays compared with other supermarket groups.
Extensive marketing of discretionary food in all Australian supermarket chains was observed, which is likely to strongly influence purchasing patterns and population diets. Findings should be used to inform private and public sector policies to reduce marketing of discretionary food in supermarkets.
Noir is a genre label with a long and complex history. The success of certain European home-grown forms of the genre (the French polar, the Scandinavian noir, etc.) invite us to reflect on the range but also the limits of the label in today’s European culture. The seemingly paradoxical example of Donald Westlake’s Ordo, an American noir novel that is perhaps neither ‘truly American’ nor ‘noir’ (and perhaps not even a ‘novel’) will serve here as a test case for some reflections on the actual use and function of the noir label in European literary culture.
OBJECTIVES/GOALS: The goal of this study is to compare plasma neurofilament light (NfL) concentrations in asymptomatic children and young adults that carry the gene expansion (GE group) that causes Huntington’s Disease to similar subjects that do not carry this genetic mutation (GNE group). METHODS/STUDY POPULATION: Subjects from the Kids-HD study in the GE group were divided into groups based on their estimated years to motor onset. Each subgroup was compared to the subjects from the GNE group. Additionally, a group of participants with juvenile HD were compared to the GNE group. These comparisons were made by utilizing linear mixed effects regression models that included a random effect per subject and family and also included the covariates of age and parental socioeconomic status. A post-hoc analysis of subjects in the GE group who were within 20 years from their predicted motor onset was conducted to assess the relationship between striatal volume and plasma NfL concentrations. RESULTS/ANTICIPATED RESULTS: GE participants more than 20 years from their predicted motor onset did not have elevated plasma NfL concentrations relative to the GNE group. However, participants who were 15-20 years from their predicted motor onset had a mean NfL concentration of 1.61 pg/uL compared to 1.31 pg/uL in the GNE group (p = 0.036). Participants who were within 15 years from their predicted motor onset had a mean NfL concentration of 2.08 pg/uL, which was also significantly elevated relative to the GNE group (t = 3.03, p = 0.003). Additionally, the participants with juvenile HD had a mean NfL level of 3.22 pg/uL, which was significantly elevated compared to the GNE group (p<0.0001). NfL concentrations were significantly correlated with striatal volume amongst participants who were within 20 years of onset (p = 0.017). DISCUSSION/SIGNIFICANCE OF IMPACT: The huntingtin protein is essential to neurodevelopment but current gene therapies for HD focus on blocking production of this gene. These results will provide guidance on the optimal timing of administration of gene therapies by identifying neurodegeneration decades prior to motor onset of HD.
In 1945, a vast range of US civic organizations and other groups were mobilized into a state-sanctioned campaign on behalf of a new international governance structure: the United Nations. This was a novel collaboration, one that demonstrated the State Department’s acknowledgment of the value of civic activity and organized interests to securing foreign policy goals and that positioned US groups to assert an independent role in shaping the formal institutions of the United Nations. While scholars of American political development (APD) have tentatively embraced the notion that international institutions matter to American politics, past research on mid-twentieth century interests, conventionally focused on domestic business and trade associations, has underappreciated how and why the United Nations marked an important movement for interest development. Of particular significance, US voluntary and civic organizations were instrumental in securing a role for nongovernmental organizations in the UN Economic and Security Council, thereby further linking American and international politics and reshaping state-society relationships. In brief, this article argues that the State Department’s campaign to mobilize public support around the United Nations, as well as the creation of the United Nations, generated new incentives for the maintenance and mobilization of existing groups and subsidized the formation of new groups.
Clinical high-risk (CHR) for psychosis is indicated by ultra-high risk (UHR) and basic symptom (BS) criteria; however, conversion rates are highest when both UHR and BS criteria are fulfilled (UHR&BS). While BSs are considered the most immediate expression of neurobiological aberrations underlying the development of psychosis, research on neurobiological correlates of BS is scarce.
We investigated gray matter volumes (GMV) of 20 regions of interest (ROI) previously associated with UHR criteria in 90 patients from the Bern early detection service: clinical controls (CC), first-episode psychosis (FEP), UHR, BS and UHR&BS. We expected lowest GMV in FEP and UHR&BS, and highest volume in CC with UHR and BS in-between.
Significantly, lower GMV was detected in FEP and UHR&BS patients relative to CC with no other significant between-group differences. When ROIs were analyzed separately, seven showed a significant group effect (FDR corrected), with five (inferior parietal, medial orbitofrontal, lateral occipital, middle temporal, precuneus) showing significantly lower GM volume in the FEP and/or UHR&BS groups than in the CC group (Bonferroni corrected). In the CHR group, only COGDIS scores correlated negatively with cortical volumes.
This is the first study to demonstrate that patients who fulfill both UHR and BS criteria – a population that has been associated with higher conversion rates – exhibit more severe GMV reductions relative to those who satisfy BS or UHR criteria alone. This result was mediated by the BS in the UHR&BS group, as only the severity of BS was linked to GMV reductions.
Whole-genome sequencing confirmed the presence of a Malassezia pachydermatis outbreak among neonates in a neonatal intensive care unit. This technology supports the importance of adhering to infection prevention measures.
Chronic diseases are highly important for the future level and distribution of health and well-being in western societies. Consequently, it seems pertinent to assess not only efficiency of chronic care but also its impact on health equity. However, operationalisation of health equity has proven a challenging task. Challenges include identifying a relevant and measurable evaluative space. Various schools of thought in health economics have identified different outcomes of interest for equity assessment, with capabilities as a proposed alternative to more conventional economic conceptualisations. The aim of this paper is to contribute to the conceptualisation of health equity evaluation in the context of chronic disease management. We do this by firstly introducing an equity enquiry framework incorporating the capabilities approach. Secondly, we demonstrate the application and relevance of this framework through a content analysis of equity-related principles and aims in national chronic disease management guidelines and the national diabetes action plan in Denmark. Finally, we discuss how conceptualisations of equity focused on capabilities may be used in evaluation by scoping relevant operationalisations. A promising way forward in the context of chronic care evaluation may emerge from a combination of concepts of capabilities developed in economics, health sciences and psychology.
Prevention of severe mental disorders, and especially the indicated prevention, has become a main topic in psychiatric research and, consequently, a matter of ethical debates. Neuropsychiatric disorders, however, form a most heterogeneous group of disorders that, among others, strike first in different age groups, differ in outcome and in availability as well as safety of treatments, have more or less understood different aetiologies and are subject to different degrees of stigmatisation and discrimination. And, although the main focus and critic are on the accuracy of prediction and the safety of treatment, concerns and arguments vary with the different characteristics of the considered disorder.
Taking endogenous psychoses as an example, costs and benefits of an early detection, of an early intervention and of prevention research in the prodromal or premorbid phase will be reviewed. It will be argued that the best way to adhere to the major ethical principles in medicine - autonomy, nonmaleficence, beneficence and fairness - in research and clinical practice will have to be reassessed continuously against the background of the current state of knowledge as well as the public opinion. Thereby, great care has to be given to ensuring that the great expected ‘common good’ will not overcome an individual patient's right to his or her own good and that, especially in patients more vulnerable to misuse, i.e., minors and those already impaired in their decision-making capacity, autonomy is given priority.
The establishment phase of an early detection centre for prodromal psychosis is introduced and characterised, along with its detaining and promoting factors within a universal multi-payer health care system.
Across the first six years (1998–2003), users' characteristics are compared between different diagnostic groups and to the local population statistics; and, for an exemplary 12-months period (3-1-2002 to 2-28-2003), the characteristics of telephone contacts with the service are studied.
Rising steadily in number across the first three years, 872 persons, predominately of German citizenship and higher education, consulted the service until 2003, 326 with first-episode psychosis and 144 not fulfilling criteria for a current or beginning psychosis. Of the 402 putatively prodromal patients, 94% reported predictive basic symptoms, 68.9% attenuated and 20.6% transient psychotic symptoms. Most contacts by persons meeting any prodromal criterion were initiated by mental health professionals (psychiatrists or psychologists) and counselling services.
Supported by public awareness campaigns, an early detection service is well received by its users and private practitioners as reflected by the large proportion of referrals from the latter. However, persons of non-German background as well as of lower education were underrepresented indicating that these sub-groups should be approached by tailored programmes.
This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.
Early identification and treatment of schizophrenia may alleviate the symptoms, delay the onset and improve the outcome of psychosis. Thus, detection of individuals at risk during the prodromal phase is an important task. Universal approaches to screen the general population or healthy subjects at risk have not proven possible to-date. However, clinical criteria for detecting ultra-high risk individuals have been developed for specialized settings, with their implementation in interventional studies. This article examines the rationale for early detection and intervention of psychosis, along with a review of some of the current studies. These target prevention using psychological and/or pharmacological intervention strategies have demonstrated promising results in high risk individuals. The German Research Network on Schizophrenia (GRNS) is conducting two multicenter early intervention studies; one with early psychological intervention in subjects who manifest early prodromal symptoms; with the second trial applying clinical management and pharmacological early intervention in subjects experiencing late prodromal symptoms (high risk subjects). Despite the promising results, many of the current studies have small sample sizes with study durations of a short period. The full benefits of early detection and intervention should be revealed once larger and longer studies are conducted.
The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion ‘cognitive disturbances’ (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The ‘genetic risk and functional decline’ UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.
To determine whether subjects with major depressive disorder (MDD) that switch/augment therapy have higher health care costs and productivity losses compared to those who stay on therapy.
Data were derived from a national-employment-based medical and pharmacy claims database. Index date was defined based on pre-specified antidepressant prescription claims between 7/1/2002-3/31/2005. Subjects were treatment-naïve 6-months prior to index-date, continuously enrolled, and had at least one outpatient-based medical claim for MDD (ICD-9=296.2x/296.3x) during study period. Study cohorts [switchers/augmenters/maintainers] were defined based on antidepressant prescription refill pattern 12-months post index therapy. Productivity losses were defined as days absent from work for medical visits multiplied by average daily wage. Per-patient-per-year (PPPY) post-index costs were statistically (Type-1 error <0.05) compared multivariately (generalized-linear-model) and productivity losses were compared univariately (Wilcoxon-tests).
Of 7,273 individuals who meet study criteria, 40.3% (n=2,931), 1.5% (n=109), and 58.2% (n=4,233) were classified as switchers, augmenters, and maintainers, respectively. Baseline characteristics were similar across the three cohorts. Average total and depression-related healthcare costs were 1.51-1.92 times (p<.01) and 1.52-1.42 times (p<.001) greater for switchers ($9,288 and $1,388) and augmenters ($9,350 and $1,027) vs. maintainers ($6,151 and $723) after controlling for baseline characteristics. Average total and depression-related productivity losses PPPY were $2,081/$680 for switchers, $2,010/$587 for augmenters and $1,424/$437 for maintainers. These productivity losses were greater for switchers and augmenters compared to maintainers (p<.001).
MDD subjects that change therapy within 12-months of treatment initiation have higher resource costs and productivity losses compared to those who stay on the same therapy.