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In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.
The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.
This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.
The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.
State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.
Foodborne salmonellosis causes approximately 1 million illnesses annually in the United States. In the summer of 2017, we investigated four multistate outbreaks of Salmonella infections associated with Maradol papayas imported from four Mexican farms. PulseNet initially identified a cluster of Salmonella Kiambu infections in June 2017, and early interviews identified papayas as an exposure of interest. Investigators from Maryland, Virginia and Food and Drug Administration (FDA) collected papayas for testing. Several strains of Salmonella were isolated from papayas sourced from Mexican Farm A, including Salmonella Agona, Gaminara, Kiambu, Thompson and Senftenberg. Traceback from two points of service associated with illness sub-clusters in two states identified Farm A as a common source of papayas, and three voluntary recalls of Farm A papayas were issued. FDA sampling isolated four additional Salmonella strains from papayas sourced from Mexican Farms B, C and D. In total, four outbreaks were identified, resulting in 244 cases with illness onset dates from 20 December 2016 to 20 September 2017. The sampling of papayas and the collaborative work of investigative partners were instrumental in identifying the source of these outbreaks and preventing additional illnesses. Evaluating epidemiological, laboratory and traceback evidence together during investigations is critical to solving and stopping outbreaks.
In the present study, we aimed to compare anthropometric indicators as predictors of mortality in a community-based setting.
We conducted a population-based longitudinal study nested in a cluster-randomized trial. We assessed weight, height and mid-upper arm circumference (MUAC) on children 12 months after the trial began and used the trial’s annual census and monitoring visits to assess mortality over 2 years.
Children aged 6–60 months during the study.
Of 1023 children included in the study at baseline, height-for-age Z-score, weight-for-age Z-score, weight-for-height Z-score and MUAC classified 777 (76·0 %), 630 (61·6 %), 131 (12·9 %) and eighty (7·8 %) children as moderately to severely malnourished, respectively. Over the 2-year study period, fifty-eight children (5·7 %) died. MUAC had the greatest AUC (0·68, 95 % CI 0·61, 0·75) and had the strongest association with mortality in this sample (hazard ratio = 2·21, 95 % CI 1·26, 3·89, P = 0·006).
MUAC appears to be a better predictor of mortality than other anthropometric indicators in this community-based, high-malnutrition setting in Niger.
Though African-American and Latino electoral success in state legislative and congressional elections continues to occur almost entirely in majority-minority districts, minorities now have new opportunities in districts that are only 40–50% minority. This success can primarily be explained in terms of a curvilinear model that generates a “sweet spot” of maximum likelihood of minority candidate electoral success as a function of minority population share of the district and the proportion of the district that votes Republican. Past racial redistricting legal challenges often focused on cracking concentrated racial minorities to prevent the creation of majority-minority districts. Future lawsuits may also follow in the steps of recent successful court challenges against racially motivated packing that resulted in the reduction of minority population percentage in a previously majority-minority district in order to enhance minority opportunity in an adjacent non-majority-minority district.
This study originated in collaboration with Thomas Dishion because of concerns that a group format for aggressive children might dampen the effects of cognitive-behavioral intervention. Three hundred sixty aggressive preadolescent children were screened through teacher and parent ratings. Schools were randomized to receive either an individual or a group format of the child component of the same evidence-based program. The results indicate that there is variability in how group-based cognitive-behavioral intervention can affect aggressive children through a long 4-year follow-up after the end of the intervention. Aggressive children who have higher skin conductance reactivity (potentially an indicator of poorer emotion regulation) and who have a variant of the oxytocin receptor gene that may be associated with being hyperinvolved in social bonding have better outcomes in their teacher-rated externalizing behavior outcomes over time if they were seen individually rather than in groups. Analyses also indicated that higher levels of the group leaders’ clinical skills predicted reduced externalizing behavior problems. Implications for group versus individual format of cognitive-behavioral interventions for aggressive children, and for intensive training for group therapists, informed by these results, are discussed.
Dementia, a term that describes a variety of brain conditions marked by gradual, persistent and progressive cognitive decline, affects a significant proportion of older adults. Older adults with dementia are sometimes perceived less favourably than those without dementia. Furthermore, compared to persons without dementia, those with dementia are often perceived by others as having reduced personhood. This study was aimed at investigating whether differences in attitudes towards dementia and personhood perceptions vary as a function of age group, care-giver status, attitudes towards ageing, dementia knowledge, gender and education. In total 196 younger, middle-aged and older adults were recruited. Findings revealed that being a care-giver as well as having less ageist attitudes were predictive of being more comfortable around persons with dementia, having more knowledge about dementia and ascribing greater personhood to people with dementia. Those with more dementia knowledge (prior to the study) were less comfortable around people with dementia. Finally, when controlling this prior dementia knowledge, older adults were more comfortable around people with dementia compared to younger and middle-aged adults. Gender and education were not associated with any of the variables under study. Findings contribute to a better understanding of the role of age- and care-giver-related factors in the determination of attitudes towards dementia.
The aggregation of neurocognitive deficits among the non-psychotic first-degree relatives of adult- and childhood-onset schizophrenia patients suggests that there may be a common etiology for these deficits in childhood- and adult-onset illness. However, there is considerable heterogeneity in the presentation of neurobiological abnormalities, and whether there are differences in the extent of familial transmission for specific domains of cognitive function has not been systematically addressed.
We employed variance components analysis, as implemented in SOLAR-Eclipse, to evaluate the evidence of familial transmission for empirically derived composite scores representing attention, working memory, verbal learning, verbal retention, and memory for faces. We contrast estimates for adult- and childhood-onset schizophrenia families and matched community control pedigrees, and compare our findings to previous reports based on analogous neurocognitive assessments.
We observed varying degrees of familial transmission; attention and working memory yielded comparable, significant estimates for adult-onset and community control pedigrees; verbal learning was significant for childhood-onset and community control pedigrees; and facial memory demonstrated significant familial transmission only for childhood-onset schizophrenia. Model-fitting analyses indicated significant differences in familiality between adult- and childhood-onset schizophrenia for attention, working memory, and verbal learning.
By comprehensively assessing a wide range of neurocognitive domains in adult- and childhood-onset schizophrenia families, we provide additional support for specific neurocognitive domains as schizophrenia endophenotypes. Whereas comparable estimates of familial transmission for certain dimensions of cognitive functioning support a shared etiology of adult- and childhood-onset neurocognitive function, observed differences may be taken as preliminary evidence of partially divergent multifactorial architectures.
Proximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable.
We sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit.
This analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy).
Smokers who lived in homes with more restrictive household smoking rules, and/or reported having ‘important others’ who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting.
Adjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Residual herbicides are routinely applied to control troublesome weeds in pumpkin production. Fluridone and acetochlor, Groups 12 and 15 herbicides, respectively, provide broad-spectrum PRE weed control. Field research was conducted in Virginia and New Jersey to evaluate pumpkin tolerance and weed control to PRE herbicides. Treatments consisted of fomesafen at two rates, ethalfluralin, clomazone, halosulfuron, fluridone, S-metolachlor, acetochlor emulsifiable concentrate (EC), acetochlor microencapsulated (ME), and no herbicide. At one site, fluridone, acetochlor EC, acetochlor ME, and halosulfuron injured pumpkin 81%, 39%, 34%, and 35%, respectively, at 14 d after planting (DAP); crop injury at the second site was 40%, 8%, 19%, and 33%, respectively. Differences in injury between the two sites may have been due to the amount and timing of rainfall after herbicides were applied. Fluridone provided 91% control of ivyleaf morningglory and 100% control of common ragweed at 28 DAP. Acetochlor EC controlled redroot pigweed 100%. Pumpkin treated with S-metolachlor produced the most yield (10,764 fruits ha–1) despite broadcasting over the planted row; labeling requires a directed application to row-middles. A separate study specifically evaluated fluridone applied PRE at 42, 84, 126, 168, 252, 336, and 672 g ai ha–1. Fluridone resulted in pumpkin injury ≥95% when applied at rates of ≥168 g ai ha–1; significant yield loss was noted when the herbicide was applied at rates >42 g ai ha–1. We concluded that fluridone and acetochlor formulations are unacceptable candidates for pumpkin production.
Field experiments were conducted in 2012 and 2013 across four locations for a total of 6 site-years in the midsouthern United States to determine the effect of growth stage at exposure on soybean sensitivity to sublethal rates of dicamba (8.8 g ae ha−1) and 2,4-D (140 g ae ha−1). Regression analysis revealed that soybean was most susceptible to injury from 2,4-D when exposed between 413 and 1,391 accumulated growing degree days (GDD) from planting, approximately between V1 and R2 growth stages. In terms of terminal plant height, soybean was most susceptible to 2,4-D between 448 and 1,719 GDD, or from V1 to R4. However, maximum susceptibility to 2,4-D was only between 624 and 1,001 GDD or from V3 to V5 for yield loss. As expected, soybean was sensitive to dicamba for longer spans of time, ranging from 0 to 1,162 GDD for visible injury or from emergence to R2. Likewise, soybean height was most affected when dicamba exposure occurred between 847 and 1,276 GDD or from V4 to R2. Regarding grain yield, soybean was most susceptible to dicamba between 820 and 1,339 GDD or from V4 to R2. Consequently, these data indicate that soybean response to 2,4-D and dicamba can be variable within vegetative or reproductive growth stages; therefore, specific growth stage at the time of exposure should be considered when evaluating injury from off-target movement. In addition, application of dicamba near susceptible soybean within the V4 to R2 growth stages should be avoided because this is the time of maximum susceptibility. Research regarding soybean sensitivity to 2,4-D and dicamba should focus on multiple exposure times and also avoid generalizing growth stages to vegetative or reproductive.
Although research has documented factors influencing whether military personnel seek treatment for mental health problems, less research has focused on determinants of treatment-seeking for physical health problems.
To explicitly compare the barriers and facilitators of treatment-seeking for mental and physical health problems.
US soldiers (n = 2048) completed a survey with measures of barriers and facilitators of treatment-seeking for mental and physical health problems as well as measures of somatic symptoms and mental health.
The top barrier for both mental and physical health treatment-seeking was a preference for handling problems oneself. The top facilitators for both symptom types were related to treatment improving quality of life. Differential endorsement of barriers occurred for treatment of mental versus physical health symptoms. In contrast, facilitators were endorsed more for physical than for mental health treatment. While there were few gender differences, officers reported more barriers and facilitators than did enlisted personnel. Screening positive for mental or physical health problems was associated with greater endorsement of both barriers and facilitators for physical and mental health treatment, respectively.
The leading barriers and facilitators for seeking treatment for mental health and physical problems are relatively similar, suggesting that health education should consider decision-making in seeking both mental and physical healthcare. Interventions should be tailored to reduce barriers for officers and improve facilitators for junior enlisted personnel, and address barriers and facilitators for service members screening positive for a mental or physical health problem.
Declaration of interest
T.W.B. reports personal fees from TechWerks Corporation during the conduct of the study.
This chapter addresses a special category of cases in which an asserted patent is, or has been declared to be, essential to the implementation of a collaboratively developed voluntary consensus standard, and the holder of that patent has agreed to license it to implementers of the standard on terms that are fair, reasonable, and nondiscriminatory (FRAND).This chapter explores how the existence of such a FRAND commitment may affect a patent holder’s entitlement to monetary damages and injunctive relief. In addition to issues of patent law, remedies law, and contracts law, we consider the effect of competition law on this issue.
Patent systems commonly empower courts to order accused or adjudged infringers to refrain from continuing infringing conduct in the future. Some patentees file suit for the primary purpose of obtaining and enforcing an injunction against infringement by a competitor, and even in cases in which the patentee is willing to license an invention to an accused infringer for an agreed price, the indirect monetary value of an injunction against future infringement can dwarf the amount a finder of fact is likely to award as compensation for past infringement. In some of these cases, an injunction, if granted, would impose costs on accused infringers or third parties that go well beyond the more intrinsic value of the patented technology. This chapter explores the theory behind injunctive relief in patent cases, surveys the availability of this remedy in major patent systems, and suggests a general framework for courts to use when deciding whether injunctive relief is appropriate in individual cases.
This chapter discusses the law and policy of monetary awards — including exemplary damages and litigation cost recoveries — that go beyond the compensatory damages to which prevailing parties in patent litigation are normally entitled. Up to treble damages are authorized in the United States for knowing infringement, but attorney fees are awarded only in exceptional cases. The rest of the world tends toward the opposite: Attorney fees are awarded as a matter of course, but punitive damages are generally prohibited as against public policy.This chapter discusses the theory, law, and policy of enhanced damages and attorney fee awards in the United States, Europe, and Asia. While the availability of enhanced damages and fees can bring accused infringers that might otherwise “hold out” to the table, care must also be taken to ensure that it does not discourage productive learning from patents or challenges to overbroad and vague patents. Rather than endorse any single set of doctrinal rules, there is a recommendation for further research into a number of unanswered questions about current and potential future configurations, in order to inform future policymaking.
The South China Sea (SCS) is a biodiversity hotspot, however, most biodiversity surveys in the region are confined to shallow water reefs. Here, we studied the benthic habitat and fish assemblages in the upper mesophotic coral ecosystems (MCEs; 30–40 m) and SWRs (8–22 m) at three geographic locations (Luzon Strait; Palawan; and the Kalayaan Group of Islands) in the eastern SCS (also called the West Philippine Sea) using diver-based survey methods. Mean coral genera and fish species richness ranged from 17–25 (per 25 m2) and 11–17 (per 250 m2) in MCEs, respectively; although none of these were novel genera/species. Coral and fish assemblages were structured more strongly by location than by depth. Location differences were associated with the variability in benthic composition, wherein locations with higher hard coral cover had higher coral genera richness and abundance. Locations with higher algae and sand cover had higher diversity and density of fish herbivores and benthic invertivores. Fishing efforts may also have contributed to among-location differences as the highly exploited location had the lowest fish biomass. The low variation between depths may be attributed to the similar benthic composition at each location, the interconnectivity between depths due to hydrological conditions, fish motility, and the common fishing gears used in the Philippines that can likely extend beyond SWRs. Results imply that local-scale factors and anthropogenic disturbances probably dampen across-depth structuring in coral genera and fish species assemblages.