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Stressful experiences affect biological stress systems, such as the hypothalamic–pituitary–adrenal (HPA) axis. Life stress can potentially alter regulation of the HPA axis and has been associated with poorer physical and mental health. Little, however, is known about the relative influence of stressors that are encountered at different developmental periods on acute stress reactions in adulthood. In this study, we explored three models of the influence of stress exposure on cortisol reactivity to a modified version of the Trier Social Stress Test (TSST) by leveraging 37 years of longitudinal data in a high-risk birth cohort (N = 112). The cumulative stress model suggests that accumulated stress across the lifespan leads to dysregulated reactivity, whereas the biological embedding model implicates early childhood as a critical period. The sensitization model assumes that dysregulation should only occur when stress is high in both early childhood and concurrently. All of the models predicted altered reactivity, but do not anticipate its exact form. We found support for both cumulative and biological embedding effects. However, when pitted against each other, early life stress predicted more blunted cortisol responses at age 37 over and above cumulative life stress. Additional analyses revealed that stress exposure in middle childhood also predicted more blunted cortisol reactivity.
Non-invasive prenatal testing (NIPT) for the detection of foetal aneuploidy through analysis of cell-free DNA (cfDNA) in maternal blood is offered routinely by many healthcare providers across the developed world. This testing has recently been recommended for evaluative implementation in the UK National Health Service (NHS) foetal anomaly screening pathway as a contingent screen following an increased risk of trisomy 21, 18 or 13. In preparation for delivering a national service, we have implemented cfDNA-based NIPT in our Regional Genetics Laboratory. Here, we describe our validation and verification processes and initial experiences of the technology prior to rollout of a national screening service.
Data are presented from more than 1000 patients (215 retrospective and 840 prospective) from ‘high- and low-risk pregnancies’ with outcome data following birth or confirmatory invasive prenatal sampling. NIPT was by the Illumina Verifi® test.
Our data confirm a high-fidelity service with a failure rate of ~0.24% and a high sensitivity and specificity for the detection of foetal trisomy 13, 18 and 21. Secondly, the data show that a significant proportion of patients continue their pregnancies without prenatal invasive testing or intervention after receiving a high-risk cfDNA-based result. A total of 46.5% of patients referred to date were referred for reasons other than high screen risk. Ten percent (76/840 clinical service referrals) of patients were referred with ultrasonographic finding of a foetal structural anomaly, and data analysis indicates high- and low-risk scan indications for NIPT.
NIPT can be successfully implemented into NHS regional genetics laboratories to provide high-quality services. NHS provision of NIPT in patients with high-risk screen results will allow for a reduction of invasive testing and partially improve equality of access to cfDNA-based NIPT in the pregnant population. Patients at low risk for a classic trisomy or with other clinical indications are likely to continue to access cfDNA-based NIPT as a private test.
Women's parties have a unique and important role to play in the representation of women and women's issues and interests. They are neither a new nor a rare phenomenon and have emerged in a variety of contexts across time and space. And yet we know relatively little about them. This article argues that women's parties matter and that the study of women's parties matters. We contend that women's parties constitute a discrete party family; while there is a diverse range of women's parties, they can be viewed as a coherent group with similar origins, ideology, and naming patterns. This article offers the first research framework for the comparative study of women's parties. Building our knowledge of women's parties, we argue, is important for those interested in gender and politics, particularly those concerned with the representation of women's issues and interests.
Evidence on whether nutritional supplementation affects physical activity (PA) during early childhood is limited. We examined the long-term effects of lipid-based nutrient supplements (LNS) on total PA, moderate-to-vigorous PA (MVPA) and sedentary behaviour (SB) of children at 4–6 years using an accelerometer for 1 week. Their mothers were enrolled in the International Lipid-based Nutrient Supplement-DYAD randomised controlled trial in Ghana, assigned to daily LNS or multiple micronutrients (MMN) during pregnancy through 6 months postpartum or Fe and folic acid (IFA) during pregnancy and placebo for 6 months postpartum. From 6 to 18 months, children in the LNS group received LNS; the other two groups received no supplements. Analysis was done with intention to treat comparing two groups: LNS v. non-LNS (MMN+ IFA). Of the sub-sample of 375 children fitted with accelerometers, 353 provided sufficient data. Median vector magnitude (VM) count was 1374 (interquartile range (IQR) 309), and percentages of time in MVPA and SB were 4·8 (IQR 2) and 31 (IQR 8) %, respectively. The LNS group (n 129) had lower VM (difference in mean −73 (95 % CI −20, −126), P = 0·007) and spent more time in SB (LNS v. non-LNS: 32·3 v. 30·5 %, P = 0·020) than the non-LNS group (n 224) but did not differ in MVPA (4·4 v. 4·7 %, P = 0·198). Contrary to expectations, provision of LNS in early life slightly reduced the total PA and increased the time in SB but did not affect time in MVPA. Given reduced social-emotional difficulties in the LNS group previously reported, including hyperactivity, one possible explanation is less restless movement in the LNS group.
Despite emerging evidence regarding the reversibility of stunting at older ages, most stunting research continues to focus on children below 5 years of age. We aimed to assess stunting prevalence and examine the sociodemographic distribution of stunting risk among older children and adolescents in a Malaysian population.
We used cross-sectional data on 6759 children and adolescents aged 6–19 years living in Segamat, Malaysia. We compared prevalence estimates for stunting defined using the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) references, using Cohen's κ coefficient. Associations between sociodemographic indices and stunting risk were examined using mixed-effects Poisson regression with robust standard errors.
The classification of children and adolescents as stunted or normal height differed considerably between the two references (CDC v. WHO; κ for agreement: 0.73), but prevalence of stunting was high regardless of reference (crude prevalence: CDC 29.2%; WHO: 19.1%). Stunting risk was approximately 19% higher among underweight v. normal weight children and adolescents (p = 0.030) and 21% lower among overweight children and adolescents (p = 0.001), and decreased strongly with improved household drinking water sources [risk ratio (RR) for water piped into house: 0.35, 95% confidence interval (95% CI) 0.30–0.41, p < 0.001). Protective effects were also observed for improved sanitation facilities (RR for flush toilet: 0.41, 95% CI 0.19–0.88, p = 0.023). Associations were not materially affected in multiple sensitivity analyses.
Our findings justify a framework for strategies addressing stunting across childhood, and highlight the need for consensus on a single definition of stunting in older children and adolescents to streamline monitoring efforts.
Recent research implicates antibiotic use as a potential contributor to child obesity risk. In this narrative review, we examine current observational evidence on the relation between antibiotic use in early childhood and subsequent measures of child body mass.
We searched PubMed, Web of Science and the Cochrane Library to identify studies that assessed antibiotic exposure before 3 years of age and subsequent measures of body mass or risk of overweight or obesity in childhood.
We identified 13 studies published before October 2017, based on a total of 6 81 332 individuals, which examined the relation between early life antibiotic exposure and measures of child body mass. Most studies did not appropriately account for confounding by indication for antibiotic use. Overall, we found no consistent and conclusive evidence of associations between early life antibiotic use and later child body mass [minimum overall adjusted odds ratio (aOR) reported: 1.01, 95% confidence interval (95% CI) 0.98–1.04, N = 2 60 556; maximum overall aOR reported: 2.56, 95% CI 1.36–4.79, N = 616], with no clinically meaningful increases in weight reported (maximum increase: 1.50 kg at 15 years of age). Notable methodological differences between studies, including variable measures of association and inclusion of confounders, limited more comprehensive interpretations.
Evidence to date is insufficient to indicate that antibiotic use is an important risk factor for child obesity, or leads to clinically important differences in weight. Further comparable studies using routine clinical data may help clarify this association.
People with pancreatic cancer have poor survival, and management is challenging. Pancreatic cancer patients' perceptions of their care coordination and its association with their outcomes have not been well-studied. Our objective was to determine if perception of care coordination is associated with patient-reported outcomes or survival.
People with pancreatic cancer who were 1–8 months postdiagnosis (52 with completed resection and 58 with no resection) completed a patient-reported questionnaire that assessed their perceptions of care coordination, quality of life, anxiety, and depression using validated instruments. Mean scores for 15 care-coordination items were calculated and then ranked from highest (best experience) to lowest (worst experience). Associations between care-coordination scores (including communication and navigation domains) and patient-reported outcomes and survival were investigated using general linear regression and Cox regression, respectively. All analyses were stratified by whether or not the tumor had been resected.
In both groups, the highest-ranked care-coordination items were: knowing who was responsible for coordinating care, health professionals being informed about their history, and waiting times. The worst-ranked items related to: how often patients were asked about visits with other health professionals and how well they and their family were coping, knowing the symptoms they should monitor, having sufficient emotional help from staff, and access to additional specialist services. For people who had a resection, better communication and navigation scores were significantly associated with higher quality of life and less anxiety and depression. However, these associations were not statistically significant for those with no resection. Perception of cancer care coordination was not associated with survival in either group.
Significance of results:
Our results suggest that, while many core clinical aspects of care are perceived to be done well for pancreatic cancer patients, improvements in emotional support, referral to specialist services, and self-management education may improve patient-reported outcomes.
This article describes the collection of views from political science alumni via a web-based survey as a central part of efforts to review and improve the curriculum and the broader political science program at a public university. Based on the literature and on interviews with faculty members and former students, we iteratively constructed a questionnaire containing five categories of items: program structure, content/knowledge, skills, outcomes, and learning environment. These categories were intended to capture curricular elements and outcomes that include but extend beyond employment and professional-skill attainment. Graduate students contributed in meaningful ways to the effort through a research-methods course. The article discusses how results of the survey fed into the curriculum-revision process specifically and program review and assessment considerations more generally.
Antipsychotic agents have limited efficacy for Behavioral and Psychological Symptoms of Dementia (BPSD) and there are concerns about their safety. Despite this, they are frequently used for the management of BPSD. This study aimed to assess the use of antipsychotics among people on anti-dementia medicines in Australian residential aged care facilities.
Data were obtained from an individual patient unit dose packaging database covering 40 residential aged care facilities in New South Wales, Australia. Residents supplied an anti-dementia medicine between July 2008 and June 2013 were included. Prevalence of concurrent antipsychotic use was established. Incident antipsychotic users between January 2009 and December 2011 were identified. We examined initial antipsychotic dose, maximum titrated doses, type and duration of antipsychotic use, and compared use with Australian guidelines.
There were 291 residents treated with anti-dementia medicines, 129 (44%) of whom received antipsychotics concomitantly with an anti-dementia medicine. Among the 59 incident antipsychotic users, risperidone (73%) was the most commonly used antipsychotic agent. Amongst the risperidone initiators, 43% of patients had initial doses greater than 0.5 mg/day and 6% of patients exceeded 2.0 mg/day for their maximum dose. 53% of concomitant users received daily treatment for greater than six months.
Our study using records of individual patient unit dose supply, which represents the intended medication consumption schedule, shows high rates of concurrent use of antipsychotics and anti-dementia medicines and long durations of use. The use of antipsychotics in patients with dementia needs to be carefully monitored to improve patient outcomes.
I begin by examining the answer to a traditional puzzle concerning supererogatory acts: if they are good to do, why are they not required? The answer often given is that they are optional acts because they cost the agent too much. This view has parallels with the traditional view of religious sacrifice, which involves offering up something or someone valuable as a gift or victim and experiencing a ‘cost’ as part of the ritual. There are problems with the idea that costs justify the optional nature of supererogatory acts, however, and I suggest that these problems mirror the tensions that are found in Christian theology when a traditional view of sacrifice is adopted.
Informal caregiving is an integral part of the care of people with severe
mental illness, but the support needs of those providing such care are
not often met.
To determine whether interventions provided to people caring for those
with severe mental illness improve the experience of caring and reduce
We conducted a systematic review and meta-analyses of randomised
controlled trials (RCTs) of interventions delivered by health and social
care services to informal carers (i.e. family or friends who provide
support to someone with severe mental illness).
Twenty-one RCTs with 1589 carers were included in the review. There was
evidence suggesting that the carers' experience of care was improved at
the end of the intervention by psychoeducation (standardised mean
difference −1.03, 95% CI −1.69 to −0.36) and support groups (SMD =–1.16,
95% CI −1.96 to −0.36). Psychoeducation had a benefit on psychological
distress more than 6 months later (SMD =–1.79, 95% CI −3.01 to −0.56) but
not immediately post-intervention. Support interventions had a beneficial
effect on psychological distress at the end of the intervention (SMD
=–0.99, 95% CI −1.48 to −0.49) as did problem-solving bibliotherapy (SMD
=–1.57, 95% CI −1.79 to −1.35); these effects were maintained at
follow-up. The quality of the evidence was mainly low and very low.
Evidence for combining these interventions and for self-help and
self-management was inconclusive.
Carer-focused interventions appear to improve the experience of caring
and quality of life and reduce psychological distress of those caring for
people with severe mental illness, and these benefits may be gained in
first-episode psychosis. Interventions for carers should be considered as
part of integrated services for people with severe mental health
A wetland deposit from the southern Appalachian mountains of North Carolina, USA, has been radiocarbon dated and shows continuous deposition from the early Holocene to the present. Non-coastal records of Holocene paleoenvironments are rare from the southeastern USA. Increased stable carbon isotope ratios (?13C) of sedimentary organic matter and pollen percentages indicate warm, dry early- to mid-Holocene conditions. This interpretation is also supported by n-alkane biomarker data and bulk sedimentary C/N ratios. These warm, dry conditions coincide with a mid-Holocene hypsithermal, or altithermal, documented elsewhere in North America. Our data indicate that the southeastern USA warmed concurrently with much of the rest of the continent during the mid-Holocene. If the current "warming hole" in the southeastern USA persists, during a time of greenhouse gas-induced warming elsewhere, it will be anomalous both in space and time.
This volume not only defines medievalism's margins, as well as its role in marginalizing other fields, ideas, people, places, and events, but also provides tools and models for exploring those issues and indicates new subjects to which they might apply. The eight opening essays address the physical marginalizing of medievalism in annotated texts on medieval studies; the marginalism of oneself via medievalism; medievalism's dearth of ecotheory and religious studies; academia's paucity of pop medievalism; and the marginalization of races, ethnicities, genders, sexual orientations, and literary characters in contemporary medievalism. The seven subsequent articles build on this foundation while discussing: the distancing of oneself (and others) during imaginary visits to the Middle Ages; lessons from the margins of Brazilian medievalism; mutual marginalization among factions of Spanish medieval studies; and medievalism in the marginalization of lower socio-economic classes in late-eighteenth- and early nineteenth-century Spain, of modern gamers, of contemporary laborers, and of Alfred Austin, a late-nineteenth- and early twentieth-century poet also known as Alfred the Little. In thus investigating the margins of and marginalization via medievalism, the volume affirms their centrality to the field. Karl Fugelso is Professor of Art History at Towson University in Baltimore, Maryland. Contributors: Nadia R. Altschul, Megan Arnott, Jaume Aurell, Juan Gomis Coloma, Elizabeth Emery, Vincent Ferré, Valerie B. Johnson, Alexander L. Kaufman, Erin Felicia Labbie, VickieLarsen, Kevin Moberly, Brent Moberly, Alicia C. Montoya, Serina Patterson, Jeff Rider, Lindsey Simon-Jones, Richard Utz, Helen Young.