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 firstname.lastname@example.org
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.
Since the advent of direct-acting antiviral therapy, the elimination of hepatitis c virus (HCV) as a public health concern is now possible. However, identification of those who remain undiagnosed, and re-engagement of those who are diagnosed but remain untreated, will be essential to achieve this. We examined the extent of HCV infection among individuals undergoing liver function tests (LFT) in primary care. Residual biochemistry samples for 6007 patients, who had venous blood collected in primary care for LFT between July 2016 and January 2017, were tested for HCV antibody. Through data linkage to national and sentinel HCV surveillance databases, we also examined the extent of diagnosed infection, attendance at specialist service and HCV treatment for those found to be HCV positive. Overall HCV antibody prevalence was 4.0% and highest for males (5.0%), those aged 37–50 years (6.2%), and with an ALT result of 70 or greater (7.1%). Of those testing positive, 68.9% had been diagnosed with HCV in the past, 84.9% before the study period. Most (92.5%) of those diagnosed with chronic infection had attended specialist liver services and while 67.7% had ever been treated only 38% had successfully cleared infection. More than half of HCV-positive people required assessment, and potentially treatment, for their HCV infection but were not engaged with services during the study period. LFT in primary care are a key opportunity to diagnose, re-diagnose and re-engage patients with HCV infection and highlight the importance of GPs in efforts to eliminate HCV as a public health concern.
The coronavirus disease (COVID-19) pandemic has presented unique challenges to pediatric emergency medicine (PEM) departments. The purpose of this study was to identify these challenges and ascertain how centers overcame barriers in creating solutions to continue to provide high-quality care and keep their workforce safe during the early pandemic.
This is a qualitative study based on semi-structured interviews with physicians in leadership positions who have disaster or emergency management experience. Participants were identified through purposive sampling. Interviews were recorded and transcribed electronically. Themes and codes were extracted from the transcripts by 2 independent coders. Constant comparison analysis was performed until thematic saturation was achieved. Member-checking was completed to ensure trustworthiness.
Fourteen PEM-trained physicians participated in this study. Communication, leadership and planning, clinical practice, and personal adaptations were the principal themes identified. Recommendations elicited include improving communication strategies; increasing emergency department (ED) representation within hospital-wide incident command; preparing for a surge and accepting adult patients; personal protective equipment supply and usage; developing testing strategies; and adaptations individuals made to their practice to keep themselves and their families safe.
By sharing COVID-19 experiences and offering solutions to commonly encountered problems, pediatric EDs may be better prepared for future pandemics.
There is definitive evidence for effectiveness of thrombectomy for acute stroke with large vessel occlusion (LVO). A clinical tool to identify patients with LVO is therefore required for effective triage and prehospital decision making. We developed the FAST VAN tool, which follows from the Heart and Stroke Foundation FAST stroke screen, with the addition of cortical features of vision, aphasia, and neglect, to differentiate from lacunar syndromes.
Consecutive acute stroke alerts initiated by emergency medical services (EMS) were prospectively analyzed from April 2017 to Jan 2021. FAST VAN signs were recorded by first responders who had received online education about the tool. These findings were compared to the presence or absence of LVO on CT angiography. Analysis was also performed by appropriateness for comprehensive stroke centers (CSC) transfer if no LVO was present. EMS providers were surveyed regarding ease of use in terms of learning the tool and using in real-world practice.
Data from 1080 consecutive acute strokes included 440 patients considered to have VAN signs by EMS. Fifty-four percent of VAN-positive patients showed LVO on CTA. Sensitivity, specificity, and accuracy were 86%, 75%, and 77%, respectively. In 204 false-positive cases, 143 (70%) were considered appropriate for evaluation at the CSC. EMS providers reported high satisfaction with learning and using the tool.
The FAST VAN tool for identification of LVO meets desired characteristics of an effective screening tool in ease of use, efficiency, and accuracy. Aphasia remains the most challenging cortical feature to identify accurately.
East of England is considered the “bread basket” of the UK, supplying domestic and global food markets but it is under pressures from policy, economic and environmental challenges. This chapter studies with a mixed-method approach the risks affecting the arable farming sector in the East of England, describing the role of knowledge networks and learning for resilience.
To assess the impact of the coronavirus disease 2019 pandemic on head and neck urgent suspected cancer referral pathways in rural areas of Wales.
A retrospective audit was conducted of 2234 head and neck urgent suspected cancer referrals received from January 2019 to November 2020.
The referrals dropped by 35 per cent in 2020 compared to the same period in 2019. The time from general practitioner referral to the first ENT appointment improved during the pandemic (8.0 vs 10.0 days; p < 0.001). Of referrals, 92.1 per cent were seen within a 14-day period in 2020, compared with 79.6 per cent in 2019 (p < 0.001). There were no differences between 2020 and 2019 in terms of: the (confirmed cancer) conversion rate (10.6 per cent vs 9.7 per cent; p = 0.60), general practitioner referral to multidisciplinary team discussion time (35.5 vs 41.5 days; p = 0.40) or general practitioner referral to initiation of treatment time (68.0 vs 78.0 days; p = 0.16).
Whilst coronavirus disease 2019 reduced the number of overall head and neck urgent suspected cancer referrals, the pathways were generally unchanged, if not slightly improved, in rural Wales.
The Women, Peace and Security (WPS) agenda and women's participation in peace processes are strongly supported by states. Yet financing to support the implementation of WPS has lagged behind overt international commitments to the agenda. WPS scholars and practitioners have highlighted the funding shortfalls for enabling WPS implementation and continued under-investment in gender-inclusive peace. In this article, we ask how much are donor states financially backing the implementation of gender-inclusive peace agreements which they promote? We use a high ambiguity-conflict model of policy implementation to explore the mechanisms of bilateral and multilateral financing for gender-inclusive peace. We trace to what extent international investments are supporting specific gender provisions in two progressive gender-inclusive peace processes, the 2016 Colombian Peace Agreement and 2015 Comprehensive Peace Agreement in the Philippines. In both case studies, we reveal a drastic gap between the international donor rhetoric and the funding. Patterns of financial investment do not follow nor support the life cycle of inclusive peace processes. We suggest key strategies for further research to address this policy and recommend that all gender provisions of peace agreements be monitored in-country and all gender-responsive investments be tracked and evaluated.
To describe the development and implementation of a novel tool designed to enhance nurse–patient communication in a major academic cancer center, which nurses can learn quickly, incorporate into their primary palliative care practice, and broadly disseminate in order to improve the patient experience.
An evidence-based empathic communication tool and educational program were designed to provide essential skills to oncology nurses in having discussions with patients about their personal values. Evaluation included nurse focus groups, pre- and post-course evaluations and interviews, and patient questionnaires.
Nurses were satisfied with the educational program and found the communication tool effective in a variety of clinical situations including discussions about personal values. Patients reported increased occurrences of these discussions when nurses utilized the framework (97% vs. 58%, p < 0.0001) and a higher quality of clinician communication (mean [SD] from 0 = very worst to 10 = very best: 7.18 [2.3] vs. 5.04 [2.9], p = 0.001).
Significance of results
Skilled, empathic communication is an essential component of high-quality primary palliative care. Oncology nurses are well suited to lead communication and provide this care as part of an interprofessional team. The training and tool described here are targeted and efficient, and prepare nurses to respond skillfully to emotion while facilitating important discussions about patient values.
Describe nutrition and physical activity practices, nutrition self-efficacy and barriers and food programme knowledge within Family Child Care Homes (FCCH) and differences by staffing.
Baseline, cross-sectional analyses of the Happy Healthy Homes randomised trial (NCT03560050).
FCCH in Oklahoma, USA.
FCCH providers (n 49, 100 % women, 30·6 % Non-Hispanic Black, 2·0 % Hispanic, 4·1 % American Indian/Alaska Native, 51·0 % Non-Hispanic white, 44·2 ± 14·2 years of age. 53·1 % had additional staff) self-reported nutrition and physical activity practices and policies, nutrition self-efficacy and barriers and food programme knowledge. Differences between providers with and without additional staff were adjusted for multiple comparisons (P < 0·01).
The prevalence of meeting all nutrition and physical activity best practices ranged from 0·0–43·8 % to 4·1–16·7 %, respectively. Average nutrition and physical activity scores were 3·2 ± 0·3 and 3·0 ± 0·5 (max 4·0), respectively. Sum nutrition and physical activity scores were 137·5 ± 12·6 (max 172·0) and 48·4 ± 7·5 (max 64·0), respectively. Providers reported high nutrition self-efficacy and few barriers. The majority of providers (73·9–84·7 %) felt that they could meet food programme best practices; however, knowledge of food programme best practices was lower than anticipated (median 63–67 % accuracy). More providers with additional staff had higher self-efficacy in family-style meal service than did those who did not (P = 0·006).
Providers had high self-efficacy in meeting nutrition best practices and reported few barriers. While providers were successfully meeting some individual best practices, few met all. Few differences were observed between FCCH providers with and without additional staff. FCCH providers need additional nutrition training on implementation of best practices.
Maternal depressive symptoms (MDS) have been linked to both child internalizing and externalizing behavior problems. Theory suggests that child attachment security may be a protective factor against the negative effects of MDS. This study examined child attachment security as a buffer of the link between MDS and child internalizing and externalizing behavior problems at two time points in a predominantly African American sample. Participants included mothers (N = 164; Mage = 29.68 years; 76% African American) and their preschool-aged children (60% girls; Mage = 44.67 months) recruited from four Head Start centers in low-income neighborhoods in Baltimore, Maryland. MDS were concurrently associated with child internalizing and externalizing behavior problems at both time points. No significant main effects of child attachment security on behavior problems emerged; however, child attachment moderated the association between MDS and child internalizing behavior problems at Time 2, such that MDS predicted greater child internalizing problems when attachment security was low, and the effect was attenuated when attachment security was high. No interaction emerged for child externalizing problems. Findings suggest that secure attachment in early childhood can serve as a protective factor in the context of parental risk. We discuss implications for intervention and the intergenerational transmission of psychopathology.
The developmental origins of psychopathology begin before birth and perhaps even prior to conception. Understanding the intergenerational transmission of psychopathological risk is critical to identify sensitive windows for prevention and early intervention. Prior research demonstrates that maternal trauma history, typically assessed retrospectively, has adverse consequences for child socioemotional development. However, very few prospective studies of preconception trauma exist, and the role of preconception symptoms of posttraumatic stress disorder (PTSD) remains unknown. The current study prospectively evaluates whether maternal preconception PTSD symptoms predict early childhood negative affectivity, a key dimension of temperament and predictor of later psychopathology. One hundred and eighteen women were recruited following a birth and prior to conception of the study child and were followed until the study child was 3–5 years old. Higher maternal PTSD symptoms prior to conception predicted greater child negative affectivity, adjusting for concurrent maternal depressive symptoms and sociodemographic covariates. In exploratory analyses, we found that neither maternal prenatal nor postpartum depressive symptoms or perceived stress mediated this association. These findings add to a limited prospective literature, highlighting the importance of assessing the mental health of women prior to conception and providing interventions that can disrupt the intergenerational sequelae of trauma.
Herbicides that inhibit very-long-chain fatty acids (VLCFAs) have been widely used for preemergence control of annual monocot and small-seeded dicot weed species, such as waterhemp, since their discovery in the 1950s. VLCFA-inhibiting herbicides are often applied in combination with active ingredients that possess residual activity on small-seeded broadleaf weeds, which can make their contribution to preemergence waterhemp control difficult to quantify. Bare-ground field experiments were designed to investigate the efficacy of eight VLCFA-inhibiting herbicides applied at their minimum and maximum labeled rates for control of Illinois waterhemp populations. Four different locations were selected, two of which contained previously characterized VLCFA inhibitor–resistant waterhemp populations in Champaign County (CHR) and McLean County (MCR). Two locations with VLCFA inhibitor–sensitive waterhemp populations included the University of Illinois South Farm in Urbana, IL, and the Orr Research Center in Perry, IL. Soils at the CHR, MCR, and Urbana locations contained greater than 3% organic matter, but less than 3% organic matter at Perry. Non-encapsulated acetochlor and alachlor controlled CHR and MCR waterhemp populations 28 d after treatment (DAT), whereas other VLCFA-inhibiting herbicides resulted in 61% and 76% control of the CHR and MCR populations, respectively. In contrast, all VLCFA-inhibiting herbicides resulted in 81% and 88% control of the Perry and Urbana waterhemp populations, respectively, 28 DAT. Waterhemp control decreased by 42 DAT, especially for the VLCFA inhibitor–resistant CHR and MCR populations. Overall, VLCFA-inhibiting herbicides remain effective for controlling sensitive waterhemp, but most are not effective for controlling VLCFA inhibitor–resistant waterhemp populations. Proper herbicide stewardship and integrated weed management practices should be implemented to maintain VLCFA-inhibiting herbicide efficacy for waterhemp management in the future.
Research among non-industrial societies suggests that body kinematics adopted during running vary between groups according to the cultural importance of running. Among groups in which running is common and an important part of cultural identity, runners tend to adopt what exercise scientists and coaches consider to be good technique for avoiding injury and maximising performance. In contrast, among groups in which running is not particularly culturally important, people tend to adopt suboptimal technique. This paper begins by describing key elements of good running technique, including landing with a forefoot or midfoot strike pattern and leg oriented roughly vertically. Next, we review evidence from non-industrial societies that cultural attitudes about running associate with variation in running techniques. Then, we present new data from Tsimane forager–horticulturalists in Bolivia. Our findings suggest that running is neither a common activity among the Tsimane nor is it considered an important part of cultural identity. We also demonstrate that when Tsimane do run, they tend to use suboptimal technique, specifically landing with a rearfoot strike pattern and leg protracted ahead of the knee (called overstriding). Finally, we discuss processes by which culture might influence variation in running techniques among non-industrial societies, including self-optimisation and social learning.
The prenatal period represents a critical time for brain growth and development. These rapid neurological advances render the fetus susceptible to various influences with life-long implications for mental health. Maternal distress signals are a dominant early life influence, contributing to birth outcomes and risk for offspring psychopathology. This prospective longitudinal study evaluated the association between prenatal maternal distress and infant white matter microstructure. Participants included a racially and socioeconomically diverse sample of 85 mother–infant dyads. Prenatal distress was assessed at 17 and 29 weeks’ gestational age (GA). Infant structural data were collected via diffusion tensor imaging (DTI) at 42–45 weeks’ postconceptional age. Findings demonstrated that higher prenatal maternal distress at 29 weeks’ GA was associated with increased fractional anisotropy, b = .283, t(64) = 2.319, p = .024, and with increased axial diffusivity, b = .254, t(64) = 2.067, p = .043, within the right anterior cingulate white matter tract. No other significant associations were found with prenatal distress exposure and tract fractional anisotropy or axial diffusivity at 29 weeks’ GA, or earlier in gestation.
Seed retention, and ultimately seed shatter, are extremely important for the efficacy of harvest weed seed control (HWSC) and are likely influenced by various agroecological and environmental factors. Field studies investigated seed-shattering phenology of 22 weed species across three soybean [Glycine max (L.) Merr.]-producing regions in the United States. We further evaluated the potential drivers of seed shatter in terms of weather conditions, growing degree days, and plant biomass. Based on the results, weather conditions had no consistent impact on weed seed shatter. However, there was a positive correlation between individual weed plant biomass and delayed weed seed–shattering rates during harvest. This work demonstrates that HWSC can potentially reduce weed seedbank inputs of plants that have escaped early-season management practices and retained seed through harvest. However, smaller individuals of plants within the same population that shatter seed before harvest pose a risk of escaping early-season management and HWSC.
In response to annual outbreaks of human cercarial dermatitis (HCD) in Lake Wanaka, New Zealand, ducks and snails were collected and screened for avian schistosomes. During the survey from 2009 to 2017, four species of Trichobilharzia were recovered. Specimens were examined both morphologically and genetically. Trichobilharzia querquedulae, a species known from four continents, was found in the visceral veins of the duck Spatula rhynchotis but the snail host remains unknown. Cercaria longicauda [i.e. Trichobilharzia longicauda (Macfarlane, 1944) Davis, 2006], considered the major aetiological agent of HCD in Lake Wanaka, was discovered, and redescribed from adults in the visceral veins of the duck Aythya novaeseelandiae and cercariae from the snail Austropeplea tomentosa. Recovered from the nasal mucosa of Ay. novaeseelandiae is a new species of Trichobilharzia that was also found to cycle naturally through Au. tomentosa. Cercariae of a fourth species of Trichobilharzia were found in Au. tomentosa but the species remains unidentified.
Ancient metamorphic processes are recorded by the formation of metallic-Pb nanospheres in zircon, a product of internal Pb mobilisation and thermally driven concentration. Here, metallic-Pb nanospheres formed within an ore deposit are characterised for the first time using high-angle annular dark field scanning transmission electron microscopy and energy-dispersive X-ray spectroscopy element-distribution mapping. Exceptional examples from the migmatite-hosted Archean–Paleoproterozoic Challenger Au deposit (Central Gawler Craton, South Australia) support widespread metallic-Pb nanosphere formation in zircon from rocks experiencing granulite-facies metamorphism. We also report new trace-element associations found with metallic-Pb nanospheres and a new mode of occurrence, in which Sc ‘haloes’ form adjacent to metallic-Pb nanospheres within the crystalline zircon lattice. This differs to previously characterised examples of metallic-Pb nanospheres associated with amorphous Si-rich glasses and unidentified Al–Ti, or Fe-bearing phases. Multiple modes of metallic-Pb nanosphere occurrences and trace-element associations suggests multiple modes of formation, probably dependant on zircon composition and metamorphic conditions. Identification of metallic-Pb nanospheres in a growing range of geological settings further highlights the mobility of Pb in zircon and the importance of detailed, nanoscale mineral characterisation, in order to constrain accurate geochronological histories for rocks within high-temperature geological environments.
The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training.
We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX).
A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed.
Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.
COVID-19 as a pandemic has disproportionately affected older adults, including those with dementia. The effects on health and social care systems has necessitated a rapid-response approach to care planning and decision-making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. In light of this, a decision-making tool to help families of persons with dementia was developed using a combination of qualitative data and evidence synthesis.
To develop a decision-aid using a combination of assessment and evidence-gathering methods for families of persons with dementia.
Semi-structured interviews with helpline staff from national end-of-life and supportive care organisations formed the basis of the tool design. Co-design with people living with dementia, current and former carers and experts in general practice and social care shaped the next stage. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken.
Output from interviews covered many topics, including trust, agency and confusion in making decisions in the context of COVID-19. The rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision-making.
Combining different sources and forms of evidence was efficient and valuable in creating a novel decision-making tool for persons with dementia and their families within the context of COVID-19. The decision-aid covered care planning, caregiver support systems, access to information and contingency considerations. Upon publication, the tool was adopted by NHS England and other leading healthcare organisations.