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Chapter 9 examines the real-time barriers to public health response that middle-income country demands caused in the context of Zika and MERS-CoV. The authors identify difficulties in identifying countries that possessed relevant biological samples and data, protracted negotiations over location, collaboration, and benefit sharing of research, and the development of standard agreements afterward that aimed at reducing transaction costs for access to crucial research inputs. This chapter drives home the implications of the changing system of pathogen sharing for US national security.
Reasoning ability has often been argued to be impaired in people with schizophrenic delusions, although evidence for this is far from convincing. This experiment examined the analogical reasoning abilities of several groups of patients, including non-deluded and deluded schizophrenics, to test the hypothesis that performance by the deluded schizophrenic group would be impaired.
Eleven deluded schizophrenics, 10 depressed subjects, seven non-deluded schizophrenics and 16 matched non-psychiatric controls, who were matched on a number of key variables, were asked to solve an analogical reasoning task.
Performance by the deluded schizophrenic group was certainly impaired when compared with the depressed and non-psychiatric control groups though less convincingly so when compared with the non-deluded schizophrenic group. The impairment shown by the deluded schizophrenic group seemed to occur at the initial stage of the reasoning task.
The particular type of impairment shown by the deluded subjects was assessed in relation to other cognitive problems already researched and the implications of these problems on reasoning tasks and theories of delusions was discussed.
We reviewed the recent literature for echocardiographic assessment of mitral valve abnormalities in children. A literature search was performed within the National Library of Medicine using the keywords “mitral regurgitation and/or stenosis, children.” The search was refined by adding the keywords “echocardiographic definition, classification, and evaluation.” Thirty-one studies were finally included. Significant advances in echocardiographic imaging of mitral valve defects, mainly due to the implementation of three-dimensional technology, contribute to a better understanding of the underlying anatomy. However, heterogeneity between classification systems of mitral valve disease severity is a serious problem. For regurgitant lesions, there is only very limited evidence from small studies that support the adoption of quantitative/semi-quantitative indexes commonly employed in adults. Despite the lack of evidence base, qualitative evaluation of regurgitation severity is often employed. For stenotic lesions, no clear categorisation based on trans-valvular echocardiography-derived “gradients” has been consistently applied to define mild, moderate, or severe obstruction across different paediatric age ranges. Quantitative parameters such as valve area have also been poorly validated in children. Adult recommendations are frequently applied without validation for the paediatric age. In conclusion, significant advances in the anatomical evaluation of mitral valve diseases have been made, thanks to three-dimensional echocardiography; however, limitations remain in the quantitative/semi-quantitative estimation of disease severity, both with respect to valvular regurgitation and stenosis. Because adult echocardiographic recommendations should not be simply translated to the paediatric age, more specific paediatric guidelines and standards for the assessment of mitral valve diseases are needed.
Advances in biomedical engineering have led to three-dimensional (3D)-printed models being used for a broad range of different applications. Teaching medical personnel, communicating with patients and relatives, planning complex heart surgery, or designing new techniques for repair of CHD via cardiac catheterisation are now options available using patient-specific 3D-printed models. The management of CHD can be challenging owing to the wide spectrum of morphological conditions and the differences between patients. Direct visualisation and manipulation of the patients’ individual anatomy has opened new horizons in personalised treatment, providing the possibility of performing the whole procedure in vitro beforehand, thus anticipating complications and possible outcomes. In this review, we discuss the workflow to implement 3D printing in clinical practice, the imaging modalities used for anatomical segmentation, the applications of this emerging technique in patients with structural heart disease, and its limitations and future directions.
New Zealand's ageing population and health inequities for Māori (Indigenous peoples) have prompted calls for innovative, culturally based approaches to improving health and wellbeing, and managing transitions in later life. This is particularly important for kaumātua (Māori elders) who, despite cultural strength and resilience, carry a significant burden in health, economic and social inequities. This paper describes the culture-centred development of a ‘tuakana‒teina’ (elder sibling‒younger sibling) peer support education programme designed to help kaumātua support other kaumātua experiencing transitions in later life. Taking a strengths-based approach that highlights ‘kaumātua mana motuhake’ (elder independence and autonomy), the study used kaupapa Māori (Māori approach, knowledge, skills, attitudes and values) and community-based participatory research methodology, to develop and pilot a culture-centred tuakana‒teina/peer education programme. Methods included establishing two advisory groups (one of kaumātua and one of sector experts); holding five focus groups with kaumātua; and running a pilot programme with 21 kaumātua. The findings demonstrate the value in a strengths-based approach that centralises Māori culture and kaumātua potential, capacity and ability, and recognises the continuing value and contribution of kaumātua to society. The study helps shift the focus from dominant stereotypes of ageing populations as a burden on society and shows the value of kaumātua supporting others during transitions in later life.
We read with interest the recent editorial, “The Hennepin Ketamine Study,” by Dr. Samuel Stratton commenting on the research ethics, methodology, and the current public controversy surrounding this study.1 As researchers and investigators of this study, we strongly agree that prospective clinical research in the prehospital environment is necessary to advance the science of Emergency Medical Services (EMS) and emergency medicine. We also agree that accomplishing this is challenging as the prehospital environment often encounters patient populations who cannot provide meaningful informed consent due to their emergent conditions. To ensure that fellow emergency medicine researchers understand the facts of our work so they may plan future studies, and to address some of the questions and concerns in Dr. Stratton’s editorial, the lay press, and in social media,2 we would like to call attention to some inaccuracies in Dr. Stratton’s editorial, and to the lay media stories on which it appears to be based.
Ho JD, Cole JB, Klein LR, Olives TD, Driver BE, Moore JC, Nystrom PC, Arens AM, Simpson NS, Hick JL, Chavez RA, Lynch WL, Miner JR. The Hennepin Ketamine Study investigators’ reply. Prehosp Disaster Med. 2019;34(2):111–113
The aim of this study was to estimate the effectiveness of first-line biologic disease modifying drugs(boDMARDs), and their approved biosimilars (bsDMARDs), compared with conventional (csDMARD) treatment, in terms of ACR (American College of Rheumatology) and EULAR (European League against Rheumatism) responses.
Systematic literature search, on eight databases to January 2017, sought ACR and EULAR data from randomized controlled trials (RCTs) of boDMARDs / bsDMARDs (in combination with csDMARDs, or monotherapy). Two adult populations: methotrexate (MTX)-naïve patients with severe active RA; and csDMARD-experienced patients with moderate-to-severe active RA. Network meta-analyses (NMA) were conducted using a Bayesian Markov chain Monte Carlo simulation using a random effects model with a probit link function for ordered categorical.
Forty-six RCTs met the eligibility criteria. In the MTX-naïve severe active RA population, no biosimilar trials meeting the inclusion criteria were identified. MTX plus methylprednisolone (MP) was most likely to achieve the best ACR response. There was insufficient evidence that combination boDMARDs was superior to intensive (two or more) csDMARDs. In the csDMARD-experienced, moderate-to-severe RA population, the greatest effects for ACR responses were associated with tocilizumab (TCZ) monotherapy, and combination therapy (plus MTX) with bsDMARD etanercept (ETN) SB4, boDMARD ETN and TCZ. These treatments also had the greatest effects on EULAR responses. No clear differences were found between the boDMARDs and their bsDMARDs.
In MTX-naïve patients, there was insufficient evidence that combination boDMARDs was superior to two or more csDMARDs. In csDMARD-experienced patients, boDMARDs and bsDMARDs were comparable and all combination boDMARDs / bsDMARDs were superior to single csDMARD.
SNP in the vitamin D receptor (VDR) gene is associated with risk of lower respiratory infections. The influence of genetic variation in the vitamin D pathway resulting in susceptibility to upper respiratory infections (URI) has not been investigated. We evaluated the influence of thirty-three SNP in eleven vitamin D pathway genes (DBP, DHCR7, RXRA, CYP2R1, CYP27B1, CYP24A1, CYP3A4, CYP27A1, LRP2, CUBN and VDR) resulting in URI risk in 725 adults in London, UK, using an additive model with adjustment for potential confounders and correction for multiple comparisons. Significant associations in this cohort were investigated in a validation cohort of 737 children in Manchester, UK. In all, three SNP in VDR (rs4334089, rs11568820 and rs7970314) and one SNP in CYP3A4 (rs2740574) were associated with risk of URI in the discovery cohort after adjusting for potential confounders and correcting for multiple comparisons (adjusted incidence rate ratio per additional minor allele ≥1·15, Pfor trend ≤0·030). This association was replicated for rs4334089 in the validation cohort (Pfor trend=0·048) but not for rs11568820, rs7970314 or rs2740574. Carriage of the minor allele of the rs4334089 SNP in VDR was associated with increased susceptibility to URI in children and adult cohorts in the United Kingdom.
Access to transition-related medical interventions (TRMIs) for transgender veterans has been the subject of substantial public interest and debate. To better inform these important conversations, the current study investigated whether undergoing hormone or surgical transition intervention(s) relates to the frequency of recent suicidal ideation (SI) and symptoms of depression in transgender veterans.
This study included a cross-sectional, national sample of 206 self-identified transgender veterans. They self-reported basic demographics, TRMI history, recent SI, and symptoms of depression through an online survey.
Significantly lower levels of SI experienced in the past year and 2-weeks were seen in veterans with a history of both hormone intervention and surgery on both the chest and genitals in comparison with those who endorsed a history of no medical intervention, history of hormone therapy but no surgical intervention, and those with a history of hormone therapy and surgery on either (but not both) the chest or genitals when controlling for sample demographics (e.g., gender identity and annual income). Indirect effect analyses indicated that lower depressive symptoms experienced in the last 2-weeks mediated the relationship between the history of surgery on both chest and genitals and SI in the last 2-weeks.
Results indicate the potential protective effect that TRMI may have on symptoms of depression and SI in transgender veterans, particularly when both genitals and chest are affirmed with one's gender identity. Implications for policymakers, providers, and researchers are discussed.
The Sasanian Empire had many large, multicultural and typically heavily defended cities. Literary sources are filled with direct or indirect references to the deportation or internal transfer of populations from one region to another, and boosting the urban population was clearly an important part of imperial economic planning, but there has been relatively little study of Sasanian urbanism. This chapter provides a timely overview by re-examining the archaeological evidence for the physical appearance and distribution of some of these urban centres, discusses their forms, and uses Google imagery to locate two previously archaeologically unrecorded cities which feature in the Arab conquest and Heraclius’ campaign shortly before. It goes on to use the excavated evidence from three city sites in Iraq, Iran and Turkmenistan to illustrate the physical appearance of residential and/or commercial quarters, and concludes with some observations on the importance of the Sasanian urban economy.
The term ‘Sasanian’ conjures a popular image of armoured knights, fire worshippers, courtly arts and conspicuous consumption, but a 400-year empire which stretched from Syria to Pakistan, recovered from the capture and death of one emperor on an eastern battlefield, and was one of Rome's biggest rivals and threats was not just built on exceptional kingship, feudalism and faith. Its success lay instead in effective bureaucracy and good management. Integrated planning for economic, military and civilian needs was fundamental, and without it the massive capital projects and military capabilities of the Sasanian state could not have been sustained. The huge number of mints known from marks on silver drachms implies a monetarised economy despite the fact that many of the mints are still physically unlocated. Moreover, many seals give the names of cities with which their owners were associated. The rapid movement of the Arab-led armies during the Islamic conquest was regularly punctuated by lengthy sieges and protracted negotiations with local commanders, which can be explained by the sheer number of cities and the scale of their defences.
Mitral valve anatomy has a significant impact on potential surgical options for patients with hypoplastic or borderline left ventricle. Papillary muscle morphology is a major component regarding this aspect. The purpose of this study was to use cardiac magnetic resonance to describe the differences in papillary muscle anatomy between normal, borderline, and hypoplastic left ventricles.
We carried out a retrospective, observational cardiac magnetic resonance study of children (median age 5.36 years) with normal (n=30), borderline (n=22), or hypoplastic (n=13) left ventricles. Borderline and hypoplastic cases had undergone an initial hybrid procedure. Morphological features of the papillary muscles, location, and arrangement were analysed and compared across groups.
All normal ventricles had two papillary muscles with narrow pedicles; however, 18% of borderline and 46% of hypoplastic cases had a single papillary muscle, usually the inferomedial type. In addition, in borderline or hypoplastic ventricles, the supporting pedicle occasionally displayed a wide insertion along the ventricular wall. The length ratio of the superolateral support was significantly different between groups (normal: 0.46±0.08; borderline: 0.39±0.07; hypoplastic: 0.36±0.1; p=0.009). No significant difference, however, was found when analysing the inferomedial type (0.42±0.09; 0.38±0.07; 0.39±0.22, p=0.39). The angle subtended between supports was also similar among groups (113°±17°; 111°±51° and 114°±57°; p=0.99). A total of eight children with borderline left ventricle underwent biventricular repair. There were no significant differentiating features for papillary muscle morphology in this subgroup.
The superolateral support can be shorter or absent in borderline or hypoplastic left ventricle cases. The papillary muscle pedicles in these patients often show a broad insertion. These changes have important implications on surgical options and should be described routinely.
As survival after cardiac surgery continues to improve, an increasing number of patients with hypoplastic left heart syndrome are reaching school age and beyond, with growing recognition of the wide range of neurodevelopmental challenges many survivors face. Improvements in fetal detection rates, coupled with advances in fetal ultrasound and MRI imaging, are contributing to a growing body of evidence that abnormal brain architecture is in fact present before birth in hypoplastic left heart syndrome patients, rather than being solely attributable to postnatal factors. We present an overview of the contemporary data on neurodevelopmental outcomes in hypoplastic left heart syndrome, focussing on imaging techniques that are providing greater insight into the nature of disruptions to the fetal circulation, alterations in cerebral blood flow and substrate delivery, disordered brain development, and an increased potential for neurological injury. These susceptibilities are present before any intervention, and are almost certainly substantial contributors to adverse neurodevelopmental outcomes in later childhood. The task now is to determine which subgroups of patients with hypoplastic left heart syndrome are at particular risk of poor neurodevelopmental outcomes and how that risk might be modified. This will allow for more comprehensive counselling for carers, better-informed decision making before birth, and earlier, more tailored provision of neuroprotective strategies and developmental support in the postnatal period.
This article details a successful case of restitution of important antiquities stolen from the National Museum of Afghanistan in Kabul during the Afghan Civil War (1992–94). These items had been excavated by the Délégation Archéologique Française en Afghanistan at the site of Begram during 1937 and 1939 and were allocated to the museum in Kabul when the excavated finds were divided between the National Museum of Afghanistan and the Musée Guimet (Paris). In Kabul, the most important objects were put on permanent display, but they were placed in storage in 1989 when the museum was officially closed and the capital threatened by war after the withdrawal of Soviet forces. Many objects were hidden, and some are now touring in an international exhibition hosted by the British Museum in 2011.1 However, most of the Begram ivories were stolen and entered different collections. The following article discusses how a group of 20 of these exquisite carvings were acquired, conserved, exhibited, and returned to Kabul as a direct result of the negotiations for the British Museum exhibition.2 This allowed the first scientific analyses of Indian ivories of this period, and the results provided important new evidence for the extent of polychromy as well as the scale of the different unrecorded conservation treatments previously applied to these highly fragile objects.3 The objects were returned safely to Kabul in 2012. This article also sets out some of the lessons learned from this chain of events and how it can provide an example for future restitutions.
Edward A. Tiryakian was born in Bronxville, New York, in 1929. However, at the age of six months his mother, who was of Armenian extraction, took him to France, and he was educated there from 1935 to 1939. On September 1, 1939, the day that World War II began, he and his mother boarded a ship in order to return to the United States. This was under strong advice from an American consul. His subsequent education led to his graduation from A. B. Davis High School, Mount Vernon, New York, where he was valedictorian, class of 1948. He then entered Princeton University and received a BA in sociology (summa cum laude) and was elected to Phi Beta Kappa honor society. After this he was accepted as a graduate student at Harvard, where he obtained an MA in sociology and, subsequently, a PhD (1954). His thesis was entitled, “The Evaluation of Occupations in an Underdeveloped Area: The Philippines.” Upon entering Harvard he expressed an interest in working with Talcott Parsons, and the latter encouraged him to read Emile Durkheim in the original French. This interest in things French led him to a great knowledge of French (as well as German and Russian) philosophy.
Tiryakian developed an ever-expanding interest in “foreign” countries and their literatures, and it was in these terms that he was led to pursue dissertation research in the Philippines and to travel extensively in sub-Saharan Africa. This was a period of the burgeoning of interest in modernization, and it was in this particular context that he encountered the work of the French sociologist Georges Balandier, who was to become a close friend. The latter introduced him to a number of Francophone social scientists who belonged to a recently established organization, the International Association of French Speaking Sociologists (AISLF). This association had recently been launched by Georges Gurvitch and Henri Janne. Tiryakian was to become the only American to be elected to its executive committee and was elected to the presidency for the period 1988–92.
Tiryakian taught at Princeton University from 1956 to 1962 and at Harvard from 1962 to 1965. His first full-time academic appointment was at Duke University (1965), and there he rose to the rank of full professor in 1967, eventually retiring as professor emeritus in 2004.