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OBJECTIVES/SPECIFIC AIMS: The objective of this project is to determine whether HRV, collected peri-operatively, is predictive of cognitive decline among older adults who undergo elective surgery/anesthesia. METHODS/STUDY POPULATION: This project is a part of the ongoing INTUIT/PRIME study, which is collecting pre- and post-operative cognitive testing, fMRI imaging, CSF samples, and EEG recordings from 200 older adults (age ≥ 60) undergoing elective non-cardiac/non-neurologic surgery scheduled to last > 2 hours at Duke University Medical Center and Duke Regional Hospital. This project utilizes data from the first 60 INTUIT participants who contributed continuous heart rate data before and during surgery. Participants undergo cognitive testing prior to surgery (baseline) and at 6 weeks after surgery. Our primary dependent variable is the change in the composite score from baseline to 6-weeks. Delirium is assessed in the hospital with the twice daily 3D-CAM tool, so we will report the proportion of individuals with 6-week cognitive decline who exhibited delirium in the days following surgery. Participants’ echocardiogram (ECG) recordings are extracted pre- and intraoperatively from B650/B850 patient monitors with VSCapture software. HRV is defined as the variability between successive R-spikes or inter-beat-intervals on ECG. RESULTS/ANTICIPATED RESULTS: We anticipate that lower intraoperative HRV is associated with worse cognitive decline at 6 weeks after surgery. As secondary objectives, we will determine whether pre-operative HRV or change in HRV (from pre-operative to intra-operative measures) are predictive of cognitive decline after surgery. We expect that in-hospital delirium will be detected in a higher proportion of those with 6-week cognitive decline, compared to those with stable or improved cognition at 6 weeks. DISCUSSION/SIGNIFICANCE OF IMPACT: HRV may address the present need for pre- and intra-operative cognitive risk stratification in the elderly. Physiological indices like HRV have the potential to dramatically change our understanding of CI in older adults undergoing surgery, as they offer an accessible, cost-effective, and non-invasive means whereby clinicians, particularly those unfamiliar with the nuances of geriatric and CI/dementia-related care, can monitor patients and refer those at high-risk of CI after surgery for early intervention.
To many observers across the political spectrum, American democracy appears under threat. What does the Trump presidency portend for American politics? How much confidence should we have in the capacity of American institutions to withstand this threat? We argue that understanding what is uniquely threatening to democracy requires looking beyond the particulars of Trump and his presidency. Instead, it demands a historical and comparative perspective on American politics. Drawing on insights from the fields of comparative politics and American political development, we argue that Trump’s election represents the intersection of three streams in American politics: polarized two-party presidentialism; a polity fundamentally divided over membership and status in the political community, in ways structured by race and economic inequality; and the erosion of democratic norms. The current political circumstance threatens the American democratic order because of the interactive effects of institutions, identity, and norm-breaking.
Angiostrongylus cantonensis (rat lungworm), a parasitic nematode, is expanding its distribution. Human infection, known as angiostrongyliasis, may manifest as eosinophilic meningitis, an emerging infectious disease. The range and incidence of this disease are expanding throughout the tropics and subtropics. Recently, the Hawaiian Islands have experienced an increase in reported cases. This study addresses factors affecting the parasite's distribution and projects its potential future distribution, using Hawaii as a model for its global expansion. Specimens of 37 snail species from the Hawaiian Islands were screened for the parasite using PCR. It was present on five of the six largest islands. The data were used to generate habitat suitability models for A. cantonensis, based on temperature and precipitation, to predict its potential further spread within the archipelago. The best current climate model predicted suitable habitat on all islands, with greater suitability in regions with higher precipitation and temperatures. Projections under climate change (to 2100) indicated increased suitability in regions with estimated increased precipitation and temperatures, suitable habitat occurring increasingly at higher elevations. Analogously, climate change could facilitate the spread of A. cantonensis from its current tropical/subtropical range into more temperate regions of the world, as is beginning to be seen in the continental USA.
The study of party system institutionalization in Latin America is complicated by the fact that political development in the region has been indelibly marked by period-specific stages and challenges of capitalist development. These periods are associated with distinct patterns of social mobilization, class conflict and political incorporation or exclusion of labour and popular constituencies. These patterns heavily condition the programmatic structuring of partisan competition and its impact on party system institutionalization. Important theoretical insights can be derived from the study of intra-regional variation in period-specific challenges and effects, but this requires careful attention to the factors that differentiate cases.
Policymakers may wish to align healthcare payment and quality of care while minimizing unintended consequences, particularly for safety net hospitals.
To determine whether the 2008 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy had a differential impact on targeted healthcare-associated infection rates in safety net compared with non–safety net hospitals.
Interrupted time-series design.
SETTING AND PARTICIPANTS
Nonfederal acute care hospitals that reported central line–associated bloodstream infection and ventilator-associated pneumonia rates to the Centers for Disease Control and Prevention’s National Health Safety Network from July 1, 2007, through December 31, 2013.
We did not observe changes in the slope of targeted infection rates in the postpolicy period compared with the prepolicy period for either safety net (postpolicy vs prepolicy ratio, 0.96 [95% CI, 0.84–1.09]) or non–safety net (0.99 [0.90–1.10]) hospitals. Controlling for prepolicy secular trends, we did not detect differences in an immediate change at the time of the policy between safety net and non–safety net hospitals (P for 2-way interaction, .87).
The Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy did not have an impact, either positive or negative, on already declining rates of central line–associated bloodstream infection in safety net or non–safety net hospitals. Continued evaluations of the broad impact of payment policies on safety net hospitals will remain important as the use of financial incentives and penalties continues to expand in the United States.
Party system change during the transition from ISI to neoliberalism cannot be understood merely by analyzing political alignments and events during the critical juncture itself. Neither can it be understood by examining national cases in isolation from others. A comparative perspective suggests that different countries entered the transition period with distinct antecedent conditions that shaped their respective critical junctures. As such, the causal chains that produced the divergent political outcomes of neoliberal critical junctures can be traced back to development patterns during the ISI era – that is, to the institutional legacies of the earlier, labor – incorporating critical junctures that ushered in the era of mass politics in Latin America.
This chapter and the next explore the party system effects of these two critical junctures. They trace the development of elitist and labor-mobilizing (LM) party systems following the first critical juncture, locate them within their different political economies, and explain why the LM cases were susceptible to more severe political and economic crises during the transition to market liberalism. These two critical junctures demarcate three distinct eras of socioeconomic and political development in Latin America, each of which possessed an alignment of states, markets, and societal actors that shaped national party systems. The first of these alignments, the oligarchic order, was characterized by elite political domination, commodity-export development models, and exclusive, oligarchic party systems. This order prevailed from independence in the early 19th century until the early decades of the 20th century, when industrialization, labor mobilization, and eventually the Great Depression undermined oligarchic rule and launched a new era of mass politics. This critical juncture led to the emergence of what Cavarozzi (1994) calls the state-centric matrix, which was characterized by state-led industrialization, corporatist patterns of interest intermediation, and the formation – in part of the region – of mass parties with programmatic linkages to organized labor.
The process of market globalization – understood as the transnational integration of markets for goods, services, and capital – is inevitably shaped by the particularities of world regions (Katzenstein 2005; Stallings 1995), including their distinctive patterns of political development and their modes of insertion in the global economy. The realignment of states, markets, and social actors associated with globalization and market liberalization in late 20th-century Latin America occurred in a context of redemocratization that inevitably imposed major adjustment burdens on political parties. Although democratization restored parties to political prominence after extended periods of military rule, the “dual transitions” to democracy and economic liberalism were deeply unsettling to party systems in much of the region.
The economic crises of the early 1980s undermined military governments and helped trigger democratic transitions (see Remmer 1992–1993), but they also imposed political costs on incumbent parties after democracy had been installed. Although the ensuing process of market liberalization may have contributed to the stabilization of new democratic regimes by defeating hyperinflation and forging a technocratic consensus in key areas of public policy, it also eroded many of the social and programmatic linkages that bound parties to popular constituencies. Indeed, market liberalization inevitably clashed with modes of political representation that had been forged during a half-century of state-led capitalist development.
As shown in Chapter 5, antecedent structural and institutional conditions weighed heavily on the political dynamics of neoliberal critical junctures. The transition from ISI to market liberalism was associated with more severe economic crises, greater electoral volatility, and deeper electoral realignments in countries that developed LM party systems during the ISI era. If political outcomes were fully determined by antecedent conditions, however, there would be no reason to characterize the transition to neoliberalism as a critical juncture; political change would merely reflect the unfolding of earlier, path-dependent development trajectories beset by exogenous shocks. For this transition to constitute a critical juncture, political outcomes and their institutional legacies must also be conditioned by the competitive alignments and strategic choices of political actors who ultimately decide on policy and/or institutional change.
During neoliberal critical junctures, the most important strategic choice was the adoption of structural adjustment policies in response to the exhaustion of the ISI model and the exogenous shock of the debt crisis. Although every country in the region adopted market reforms, the political consequences of such reforms varied widely depending on the political orientation and partisan alignment of supporters and opponents of the reform process. These alignments enhanced the programmatic structuring of some party systems – in both elitist and LM cases – contributing to relatively stable forms of post-adjustment partisan competition. In others, however – a majority of cases – they undermined or failed to produce programmatic structuration, destabilizing party systems in the aftermath period. Indeed, reactive sequences in the aftermath period – driven largely by societal resistance to market liberalism – sometimes altered the institutional outcomes of the critical juncture itself; party systems that were relatively stable during the critical juncture encountered new disruptive forces in the aftermath period, while in a few cases inchoate and volatile party systems progressively consolidated.
This book began as a relatively straightforward attempt to understand why some party systems are more stable than others in Latin America, but it quickly evolved into a larger and more ambitious effort to identify the impact of economic crises and market reforms on democratic representation. Ultimately, it sought to explain how and why a transition from one economic era to another was also a major turning point in Latin America’s political development. I began, perhaps naively, to conceive of that economic transition as a critical juncture in political development long before I was able to identify the full range of its institutional effects, much less its longer-term political legacies. To put it in Gramsci’s more eloquent terms from the epigraph, I began this project in a moment of crisis in Latin America, an interregnum “when the old was dying and the new could not be born,” and a great variety of “morbid” (and often fleeting) symptoms appeared. Enough time has now passed for me to hazard a claim that new political orders were born during this watershed period, even if some of them veered off in unexpected directions or remain institutionally fluid (as the reader will quickly discover). The purpose of this book is to trace where these new orders came from, explain why some are more stable than others, and identify what makes them different, both from each other and from the political orders that preceded them.
Any research project this long in the making is bound to incur debts to individuals and institutions that are too numerous to mention. That is surely the case with this book. Although I cannot acknowledge everyone who deserves to be thanked, I want to at least recognize a number of individuals who made especially vital contributions. From the outset of this project, Ruth Berins Collier and David Collier provided intellectual inspiration and constructive feedback. They have been remarkably generous in supporting my efforts to build upon the intellectual foundation they laid in their study of earlier critical junctures in Latin America. I also learned a great deal from intensive workshops centered on earlier drafts of my book that were organized by Erik Wibbels and Margaret Levi at the University of Washington, Jorge Lanzaro at the Universidad de la República in Uruguay, and Juan Pablo Luna at the Universidad Católica in Chile.