To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
To describe epidemiologic and genomic characteristics of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a large skilled-nursing facility (SNF), and the strategies that controlled transmission.
Design, setting, and participants:
This cohort study was conducted during March 22–May 4, 2020, among all staff and residents at a 780-bed SNF in San Francisco, California.
Contact tracing and symptom screening guided targeted testing of staff and residents; respiratory specimens were also collected through serial point prevalence surveys (PPSs) in units with confirmed cases. Cases were confirmed by real-time reverse transcription–polymerase chain reaction testing for SARS-CoV-2, and whole-genome sequencing (WGS) was used to characterize viral isolate lineages and relatedness. Infection prevention and control (IPC) interventions included restricting from work any staff who had close contact with a confirmed case; restricting movement between units; implementing surgical face masking facility-wide; and the use of recommended PPE (ie, isolation gown, gloves, N95 respirator and eye protection) for clinical interactions in units with confirmed cases.
Of 725 staff and residents tested through targeted testing and serial PPSs, 21 (3%) were SARS-CoV-2 positive: 16 (76%) staff and 5 (24%) residents. Fifteen cases (71%) were linked to a single unit. Targeted testing identified 17 cases (81%), and PPSs identified 4 cases (19%). Most cases (71%) were identified before IPC interventions could be implemented. WGS was performed on SARS-CoV-2 isolates from 4 staff and 4 residents: 5 were of Santa Clara County lineage and the 3 others were distinct lineages.
Early implementation of targeted testing, serial PPSs, and multimodal IPC interventions limited SARS-CoV-2 transmission within the SNF.
Apathy is a very common behavioural and psychological symptom across brain disorders. In the last decade, there have been considerable advances in research on apathy and motivation. It is thus important to revise the apathy diagnostic criteria published in 2009. The main objectives were to: a) revise the definition of apathy; b) update the list of apathy dimensions; c) operationalise the diagnostic criteria; and d) suggest appropriate assessment tools including new technologies.
The expert panel (N = 23) included researchers and health care professionals working on brain disorders and apathy, a representative of a regulatory body, and a representative of the pharmaceutical industry. The revised diagnostic criteria for apathy were developed in a two-step process. First, following the standard Delphi methodology, the experts were asked to answer questions via web-survey in two rounds. Second, all the collected information was discussed on the occasion of the 26th European Congress of Psychiatry held in Nice (France).
Apathy was defined as a quantitative reduction of goal-directed activity in comparison to the patient’s previous level of functioning (criterion A). Symptoms must persist for at least four weeks, and affect at least two of the three apathy dimensions (behaviour/cognition; emotion; social interaction; criterion B). Apathy should cause identifiable functional impairments (criterion C), and should not be fully explained by other factors, such as effects of a substance or major changes in the patient’s environment (Criterion D).
Apathy diagnostic criteria 2018.
CRITERION A: A quantitative reduction of goal-directed activity either in behavioral, cognitive, emotional or social dimensions in comparison to the patient’s previous level of functioning in these areas. These changes may be reported by the patient himself/herself or by observation of others.
CRITERION B: The presence of at least 2 of the 3 following dimensions for a period of at least four weeks and present most of the time B1. BEHAVIOUR & COGNITION Loss of, or diminished, goal-directed behaviour or cognitive activity as evidenced by at least one of the following: General level of activity: the patient has a reduced level of activity either at home or work, makes less effort to initiate or accomplish tasks spontaneously, or needs to be prompted to perform them. Persistence of activity: He/she is less persistent in maintaining an activity or conversation, finding solutions to problems or thinking of alternative ways to accomplish them if they become difficult. Making choices: He/she has less interest or takes longer to make choices when different alternatives exist (e.g., selecting TV programs, preparing meals, choosing from a menu, etc.) Interest in external issue: He/she has less interest in or reacts less to news, either good or bad, or has less interest in doing new things Personal wellbeing: He/she is less interested in his/her own health and wellbeing or personal image (general appearance, grooming, clothes, etc.). B2. EMOTION Loss of, or diminished, emotion as evidenced by at least one of the following: Spontaneous emotions: the patient shows less spontaneous (self-generated) emotions regarding their own affairs, or appears less interested in events that should matter to him/her or to people that he/she knows well. Emotional reactions to environment: He/she expresses less emotional reaction in response to positive or negative events in his/her environment that affect him/her or people he/she knows well (e.g., when things go well or bad, responding to jokes, or events on a TV program or a movie, or when disturbed or prompted to do things he/she would prefer not to do). Impact on others: He/she is less concerned about the impact of his/her actions or feelings on the people around him/her. Empathy: He/she shows less empathy to the emotions or feelings of others (e.g., becoming happy or sad when someone is happy or sad, or being moved when others need help). Verbal or physical expressions: He/she shows less verbal or physical reactions that reveal his/her emotional states. B3. SOCIAL INTERACTION Loss of, or diminished engagement in social interaction as evidenced by at least one of the following: Spontaneous social initiative: the patient takes less initiative in spontaneously proposing social or leisure activities to family or others. Environmentally stimulated social interaction: He/she participates less, or is less comfortable or more indifferent to social or leisure activities suggested by people around him/her. Relationship with family members: He/she shows less interest in family members (e.g., to know what is happening to them, to meet them or make arrangements to contact them). Verbal interaction: He/she is less likely to initiate a conversation, or he/she withdraws soon from it Homebound: He /She prefer to stays at home more frequently or longer than usual and shows less interest in getting out to meet people.
CRITERION C These symptoms (A - B) cause clinically significant impairment in personal, social, occupational, or other important areas of functioning.
CRITERION D The symptoms (A - B) are not exclusively explained or due to physical disabilities (e.g. blindness and loss of hearing), to motor disabilities, to a diminished level of consciousness, to the direct physiological effects of a substance (e.g. drug of abuse, medication), or to major changes in the patient’s environment.
The new diagnostic criteria for apathy provide a clinical and scientific framework to increase the validity of apathy as a clinical construct. This should also help to pave the path for apathy in brain disorders to be an interventional target.
We analyzed birth order differences in means and variances of height and body mass index (BMI) in monozygotic (MZ) and dizygotic (DZ) twins from infancy to old age. The data were derived from the international CODATwins database. The total number of height and BMI measures from 0.5 to 79.5 years of age was 397,466. As expected, first-born twins had greater birth weight than second-born twins. With respect to height, first-born twins were slightly taller than second-born twins in childhood. After adjusting the results for birth weight, the birth order differences decreased and were no longer statistically significant. First-born twins had greater BMI than the second-born twins over childhood and adolescence. After adjusting the results for birth weight, birth order was still associated with BMI until 12 years of age. No interaction effect between birth order and zygosity was found. Only limited evidence was found that birth order influenced variances of height or BMI. The results were similar among boys and girls and also in MZ and DZ twins. Overall, the differences in height and BMI between first- and second-born twins were modest even in early childhood, while adjustment for birth weight reduced the birth order differences but did not remove them for BMI.
A trend toward greater body size in dizygotic (DZ) than in monozygotic (MZ) twins has been suggested by some but not all studies, and this difference may also vary by age. We analyzed zygosity differences in mean values and variances of height and body mass index (BMI) among male and female twins from infancy to old age. Data were derived from an international database of 54 twin cohorts participating in the COllaborative project of Development of Anthropometrical measures in Twins (CODATwins), and included 842,951 height and BMI measurements from twins aged 1 to 102 years. The results showed that DZ twins were consistently taller than MZ twins, with differences of up to 2.0 cm in childhood and adolescence and up to 0.9 cm in adulthood. Similarly, a greater mean BMI of up to 0.3 kg/m2 in childhood and adolescence and up to 0.2 kg/m2 in adulthood was observed in DZ twins, although the pattern was less consistent. DZ twins presented up to 1.7% greater height and 1.9% greater BMI than MZ twins; these percentage differences were largest in middle and late childhood and decreased with age in both sexes. The variance of height was similar in MZ and DZ twins at most ages. In contrast, the variance of BMI was significantly higher in DZ than in MZ twins, particularly in childhood. In conclusion, DZ twins were generally taller and had greater BMI than MZ twins, but the differences decreased with age in both sexes.
For over 100 years, the genetics of human anthropometric traits has attracted scientific interest. In particular, height and body mass index (BMI, calculated as kg/m2) have been under intensive genetic research. However, it is still largely unknown whether and how heritability estimates vary between human populations. Opportunities to address this question have increased recently because of the establishment of many new twin cohorts and the increasing accumulation of data in established twin cohorts. We started a new research project to analyze systematically (1) the variation of heritability estimates of height, BMI and their trajectories over the life course between birth cohorts, ethnicities and countries, and (2) to study the effects of birth-related factors, education and smoking on these anthropometric traits and whether these effects vary between twin cohorts. We identified 67 twin projects, including both monozygotic (MZ) and dizygotic (DZ) twins, using various sources. We asked for individual level data on height and weight including repeated measurements, birth related traits, background variables, education and smoking. By the end of 2014, 48 projects participated. Together, we have 893,458 height and weight measures (52% females) from 434,723 twin individuals, including 201,192 complete twin pairs (40% monozygotic, 40% same-sex dizygotic and 20% opposite-sex dizygotic) representing 22 countries. This project demonstrates that large-scale international twin studies are feasible and can promote the use of existing data for novel research purposes.
Ethnographic Observations: Trained members of the research team visited each club to conduct ethnographic observations, typically two times a week, beginning in September and continuing through the end of the school year in June. Observers recorded detailed field notes after each visit (see Field Note Template later in this appendix). Each field note included the team member’s observations and reflections as well as an account of any conversations with youth or staff. The principal investigator (Hirsch) reviewed the field notes on an ongoing basis. Developments or issues that might benefit from additional investigation were highlighted for follow-up during subsequent visits to the club.
Social Climate Ratings: Following each visit to a club, the research team member involved completed ratings of the social climate of the club on several different dimensions, such as cooperation and conflict among staff and youth enjoyment and participation in decision making (see Field Note Template later in this appendix).
All Youth Attending Each Center
Youth Background Questionnaire: This questionnaire was completed at the start of the year by all youth at each of the clubs who were ten years of age or older. The survey included questions that asked youth for basic demographic information, their levels and history of participation in the club, how safe they felt in their neighborhoods, and whether they experienced the club setting as a “second home.” Each youth also was asked on the survey to identify the staff person at the center with whom he or she had the closest relationship.
Tommiana is a somewhat typical twelve-year-old girl. With a number of friends and some close adult relationships, including with West River staff, she is active and involved in multiple activities at the center. Dance is Tommiana’s favorite activity and is led by the staff person with whom she has the closest relationship. At the same time, Tommiana is moody, and in the middle of the year begins to withdraw from the dance program. Furthermore, Tommiana stops coming to the center for a few weeks in March, after losing to a peer in a center-wide competition. No one appears to follow-up on her absence, suggesting that she may have been somewhat lost in the shuffle. In this chapter, we will see how West River provided important support for Tommiana, but also had some costs. Her case illustrates one of the strengths of a comprehensive youth center, wherein relationships with staff can spread across activities and different PARCs can complement each other. Yet it also reminds us of the importance of the fit between individual youth and a program’s culture, particularly around issues of competition. Finally, Tommiana’s story provides a look at the missed opportunities for support when staff fail to capitalize on potential linkages beyond the walls of the center.
in the beginning
Tommiana is a petite girl who prides herself on being well dressed. She has been coming to West River since she was in the first grade and most of her friends also attend the center. Tommiana tells us that she used to attend the club every day. In third grade, she stopped coming as regularly because she lived further away from West River. She reports this period of lesser attendance as a “bad” event in her history at the center. At the time of our study, she reported coming almost every day but was observed at the center less frequently as the year progressed – something we discuss further throughout the chapter.
Youth programs can be found in abundance throughout our communities. Nowhere, however, are they more prevalent than in the after-school arena. The past decade has witnessed explosive growth in after-school programs. The federal government launched a billion-dollar initiative, the 21st Century Community Learning Centers. California’s Proposition 49 channeled more than 400 million additional dollars to after-school programs. Several major foundations have put after-school programs at the core of their concerns. And city after city is scaling up its after-school programs. Much of this growth has involved after-school centers that typically are home to a wide array of programs and services. These include the Boys & Girls Clubs of America, which more than doubled the number of its clubs, from 1,800 in 1997 to 4,000 in 2008. Clearly there is a push to make after-school programs part of the educational and youth services infrastructure. We believe in the promise of after-school programs but also are concerned about the pitfalls. We have seen both good programs and bad programs, strong centers and weak centers. It is critical to understand the factors that lead to quality and to positive youth outcomes if the after-school movement is to be built on a solid foundation.
It is easy to appreciate the push for more after-school programming. This is especially true for the school-age adolescents in low-income urban communities who we studied in this research. These young people need to cope with violence and poor schools on a daily basis. Job opportunities are often few and far between. Adult role models can be in short supply as the middle class has largely abandoned these neighborhoods, many men are in prison, and parents often have work shifts that leave little time for guidance and support. After-school programs hope to step into these gaps and supplement what youth receive from family and school.
At this point, it is time to take a step back and consider what we have learned by our several studies of the Midwest after-school center. We hope in these mini-chapters – including the ones that follow the case studies of the other centers – to contribute to an integrative understanding of how comprehensive after-school centers influence youth outcomes. As part of this effort, we pay particular attention to distinctive features of comprehensive centers. Centers of this sort are complex organizations, and our analytic framework seeks to integrate both organizational and person-level factors. Grounded in the experiences of Pocahontas and Bill, as well as the organizational-level study, our objective is to abstract broader insights from those accounts. We therefore need to shift gears somewhat and consider what more general principles may be at work, which we can then reexamine in future chapters.
In Chapter 1, we introduced the concept of a PARC (program, activity, relationship, culture) to capture the multifaceted aspect of youth engagements at these centers. For both Pocahontas and Bill, this proved to be a very useful concept. For both of them it was critical to find one PARC that meaningfully engaged them. A meaningful PARC anchored their continued participation in Midwest and fostered developmental growth. Pocahontas found this with Manuel around math, Bill with Manuel around chess. In these instances, the person was an adult staff member; it may be possible for a peer to serve in this role as well, but our research was oriented toward youth relationships with adult staff, so we are not in the best position to address this question.
We now need to take stock of what broader insights can be gleaned from our studies of the West River center. As it is the last center we will be examining, we use this chapter as an opportunity to integrate our findings across our studies of all three centers. Our aim in doing so is to arrive at a set of conclusions regarding the conditions under which comprehensive after-school centers are most likely to realize their potential for promoting positive youth development. Our conclusions provide the foundation for the practice recommendations that we present in the next and final chapter.
West River is the strongest of the after-school centers we examined on most dimensions. So it is natural to use this center, and our studies of youth there (Midnight and Tomianna), as a counterpoint to many of the weaknesses and limitations that are apparent for the Midwest and North River centers. Our intention is not to suggest either that the latter centers are entirely lacking in positive features or that West River is without areas in need of improvement. Neither of these, of course, is the case. Indeed, as we will discuss, there are some concerns that stand out as in need of attention at all three centers and, we suspect, to a large degree among comprehensive after-school centers more generally. As researchers, this process of comparing and contrasting is one of our major analytic tools.
Like Pocahontas, Bill is a difficult character to miss. On the one hand, he is quintessentially “one of the guys,” shooting hoops, playing ping-pong, and tossing around the term “gay” as his insult of choice. He can be loud and disruptive, with a history of school trouble for both fighting and academic failure. Yet closer observation reveals an intelligent boy with an introspective tendency and interests in social issues, chess, and history. The Midwest after-school center serves as a safe space for Bill, a place of moratorium where he escapes the pressure of gang activity present in his school and neighborhood. His involvement in the chess club allows him to shine and develop relationships with staff. But Bill’s story is also one of missed opportunity. He would have benefited from mentoring around his grades and school conflicts. Bill is not able to fully connect with the resources he needs because his demeanor feeds into stereotypes of male self-sufficiency. His one-of-the-guys persona winds up hurting him, hiding his need for the type of interpersonal support that Pocahontas was so successful in accessing. Bill’s story illustrates a hidden danger of urban masculinity, especially in a setting such as Midwest, which is not oriented to proactive intervention.
Beyonce hardly fits the profile of risk that we have come to associate with young people living in low-income urban neighborhoods. Risk for school failure? Beyonce has made the Honor Roll the last two years and counts reading as one of her favorite pastimes. Risk for becoming involved in a gang or behaviors such as substance use, premature sexual activity, or violence? It is difficult to envision any of these scenarios on the immediate horizon for Beyonce. In fact, whereas all of these activities typically arise in the context of relationships with peers, what is most outstanding about Beyonce is her overall lack of positive or rewarding ties with other youngsters her age. Rather than getting in with the “wrong crowd,” Beyonce is experiencing great difficulty getting in with any crowd. It is precisely these distinguishing characteristics that make the experiences of this ten-year-old African-American girl during her year at the club so instructive and important. As we shall see, Beyonce’s story illustrates how after-school centers can be of significant benefit to youth whose greatest liabilities have little in common with prevailing stereotypes of urban risk. It is equally vivid in highlighting how limitations in programs, organizational practices, and mentoring can lead centers to fall well short of the mark in responding to the needs of such young people.