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The use of Alzheimer disease medication for the treatment of dementia symptoms has shown significant benefits with regards to functional and cognitive outcomes as well as nursing home placement (NHP) and mortality. Hospitalisations in these patient groups are characterised by extended length of stays (LOS), frequent readmissions, frequent NHP and high-mortality rates. The impact of Alzheimer disease medication on the aforementioned outcomes remains still unknown. This study assessed the association of Alzheimer disease medication with outcomes of hospitalisation among patients with Alzheimer disease and other forms of dementia.
A dynamic retrospective cohort study from 2004 to 2015 was conducted which claims data from a German health insurance company. People with dementia (PWD) were identified using ICD-10 codes and diagnostic measures. The main predictor of interest was the use of Alzheimer disease medication. Hospitalisation outcomes included LOS, readmissions, NHP and mortality during and after hospitalisation across four hospitalisations. Confounding was addressed using a propensity score throughout all analyses.
A total of 1380 users of Alzheimer disease medication and 6730 non-users were identified. The use of Alzheimer disease medication was associated with significantly shorter LOS during the first hospitalisations with estimates for the second, third and fourth showed a tendency towards shorter hospital stays. In addition, current users of Alzheimer disease medication had a lower risk of hospital readmission after the first two hospitalisations. These associations were not significant for the third and fourth hospitalisations. Post-hospitalisation NHP and mortality rates also tended to be lower among current users than among non-users but differences did not reach statistical significance.
Our results indicate that Alzheimer disease medication might contribute to a reduction of the LOS and the number of readmissions in PWD.
Ethical dilemmas can create moral distress in even the most experienced emergency physicians (EPs). Following reasonable and justified approaches can help alleviate such distress. The purpose of this article is to guide EPs providing Emergency Medical Services (EMS) direction to navigate through common ethical issues confronted in the prehospital delivery of care, including protecting privacy and confidentiality, decision-making capacity and refusal of treatment, withholding of treatment, and termination of resuscitation (TOR). This requires a strong foundation in the principles and theories underlying sound ethical decisions that EPs and prehospital providers make every day in good faith, but will now also make with more awareness and conscientiousness.
BrennerJM, AsweganAL, VearrierLE, BasfordJB, IsersonKV. The Ethics of Real-Time EMS Direction: Suggested Curricular Content. Prehosp Disaster Med. 2018;33(2):201–212.
Schizotypal traits are considered a phenotypic-indicator of schizotypy, a latent personality organization reflecting a putative liability for psychosis. To date, no previous study has examined the comparability of factorial structures across samples originating from different countries and cultures. The main goal was to evaluate the factorial structure and reliability of the Schizotypal Personality Questionnaire (SPQ) scores by amalgamating data from studies conducted in 12 countries and across 21 sites.
The overall sample consisted of 27 001 participants (37.5% males, n = 4251 drawn from the general population). The mean age was 22.12 years (s.d. = 6.28, range 16–55 years). The SPQ was used. Confirmatory factor analysis (CFA) and Multilevel CFA (ML-CFA) were used to evaluate the factor structure underlying the SPQ scores.
At the SPQ item level, the nine factor and second-order factor models showed adequate goodness-of-fit. At the SPQ subscale level, three- and four-factor models displayed better goodness-of-fit indices than other CFA models. ML-CFA showed that the intraclass correlation coefficients values were lower than 0.106. The three-factor model showed adequate goodness of fit indices in multilevel analysis. The ordinal α coefficients were high, ranging from 0.73 to 0.94 across individual samples, and from 0.84 to 0.91 for the combined sample.
The results are consistent with the conceptual notion that schizotypal personality is a multifaceted construct and support the validity and utility of SPQ in cross-cultural research. We discuss theoretical and clinical implications of our results for diagnostic systems, psychosis models and cross-national mental health strategies.
Clinicians need guidance to address the heterogeneity of treatment responses of patients with major depressive disorder (MDD). While prediction schemes based on symptom clustering and biomarkers have so far not yielded results of sufficient strength to inform clinical decision-making, prediction schemes based on big data predictive analytic models might be more practically useful.
We review evidence suggesting that prediction equations based on symptoms and other easily-assessed clinical features found in previous research to predict MDD treatment outcomes might provide a foundation for developing predictive analytic clinical decision support models that could help clinicians select optimal (personalised) MDD treatments. These methods could also be useful in targeting patient subsamples for more expensive biomarker assessments.
Approximately two dozen baseline variables obtained from medical records or patient reports have been found repeatedly in MDD treatment trials to predict overall treatment outcomes (i.e., intervention v. control) or differential treatment outcomes (i.e., intervention A v. intervention B). Similar evidence has been found in observational studies of MDD persistence-severity. However, no treatment studies have yet attempted to develop treatment outcome equations using the full set of these predictors. Promising preliminary empirical results coupled with recent developments in statistical methodology suggest that models could be developed to provide useful clinical decision support in personalised treatment selection. These tools could also provide a strong foundation to increase statistical power in focused studies of biomarkers and MDD heterogeneity of treatment response in subsequent controlled trials.
Coordinated efforts are needed to develop a protocol for systematically collecting information about established predictors of heterogeneity of MDD treatment response in large observational treatment studies, applying and refining these models in subsequent pragmatic trials, carrying out pooled secondary analyses to extract the maximum amount of information from these coordinated studies, and using this information to focus future discovery efforts in the segment of the patient population in which continued uncertainty about treatment response exists.
Mass changes of the Antarctic ice sheet impact sea-level rise as climate changes, but recent rates have been uncertain. Ice, Cloud and land Elevation Satellite (ICESat) data (2003–08) show mass gains from snow accumulation exceeded discharge losses by 82 ± 25 Gt a−1, reducing global sea-level rise by 0.23 mm a−1. European Remote-sensing Satellite (ERS) data (1992–2001) give a similar gain of 112 61 Gt a−1. Gains of 136 Gt a−1 in East Antarctica (EA) and 72 Gt a−1 in four drainage systems (WA2) in West Antarctic (WA) exceed losses of 97 Gt a−1 from three coastal drainage systems (WA1) and 29 Gt a−1 from the Antarctic Peninsula (AP). EA dynamic thickening of 147 Gt a−1 is a continuing response to increased accumulation (>50%) since the early Holocene. Recent accumulation loss of 11 Gt a−1 in EA indicates thickening is not from contemporaneous snowfall increases. Similarly, the WA2 gain is mainly (60 Gt a−1) dynamic thickening. In WA1 and the AP, increased losses of 66 ± 16 Gt a−1 from increased dynamic thinning from accelerating glaciers are 50% offset by greater WA snowfall. The decadal increase in dynamic thinning in WA1 and the AP is approximately one-third of the long-term dynamic thickening in EA and WA2, which should buffer additional dynamic thinning for decades.
During the first half of the sixteenth century, municipal councils across northern France issued ordinances designed to combat outbreaks of plague. The measures contained in these ordinances were extensive and formed the core of urban responses to plague throughout the early modern period. These ordinances did not appear out of a vacuum; rather, they represented the codification of stratagems adopted during the second half of the fifteenth century. This article will describe and account for the growth of the public health system developed by the magistrates of towns lying in the urban belt of northern and north-eastern France from the 1450s to the 1550s. It will concentrate on the towns and cities of Abbeville, Amiens, Beauvais, Paris, Rouen and Tournai, all of which possess good administrative records for the period. In addition to the texts of plague ordinances, the most valuable documents for this study are the registers of municipal deliberations, which allow us to follow the decision-making process that lay behind the development of plague legislation.
Many of the more celebrated measures against pestilence originated in fourteenth- and fifteenth-century Italy, and the bulk of our knowledge regarding the ways in which urban administrations reacted to these outbreaks is based on studies of northern Italian cities, such as Florence and Venice. Although historians have expanded the geographical scope of such studies to consider municipal responses to plague in England, Spain, Switzerland, Germany and the Low Countries, little research has been done on France during the fifteenth and sixteenth centuries.
This article will examine and compare the way that society coped with two of the major epidemics to affect Renaissance Italy: plague and the Great Pox. Even though these diseases impacted on Italy as severely as they did on the rest of Europe, different countries devised different solutions to the same problems. Discussing the strategies that Italy adopted in the long fifteenth century is valuable not just to those who work on Italian Renaissance history, but also to historians of countries such as England which developed very different measures. Indeed, in the sixteenth century, in the case of plague, the privy council and statesmen such as William Cecil, Lord Burghley, looked to continental and particularly Italian plague measures as a reflection of their ‘civility’, which made them worthy of imitation.
The main elements which constituted this ‘civility’ will be the subject of the first part of this article, which will examine society's reactions to plague in Renaissance Italy through the prism of how contemporaries understood the nature of the disease. One of the more traditional themes of historical studies of Italian plague is the idea that at the time there was a marked division in beliefs between doctors and health boards about how disease was spread, with the former supporting the idea of infected air, or miasma, and the latter espousing contagionist views. This story is complicated still further from the late fifteenth century by the emergence of the Great Pox.
John Clement, a brewer, entered the Norwich franchise in 1447. Over the next decade he was a constable nine times and a tax collector once, but he never discharged any other civic office. In spite of their important role in administering and maintaining order in English cities, men like Clement have been neglected as a result of English urban historians' tendency to focus on the better-documented and wealthier mercantile elite. Prosopographical analyses of urban political, economic, and social groups have directed some attention towards middling artisans and retailers because of their focus on collective biography, but the relative dearth of information about these groups has made even this approach more effective for understanding the senior officials. Moreover, although these studies have revealed much about civic hierarchies, they have perhaps encouraged the perception that a mercantile elite dominated all aspects of urban political life. Although no one would deny the virtual monopoly of high office by a privileged few, there is considerable evidence that mercantile control was not so comprehensive in the lower levels of civic government.
Non-elite urban officials have received little sustained analysis. Indeed, on the few occasions that mid-level offices have been examined they have generally been cast as part of the cursus honorum or as unwelcome chores rather than as potentially valuable positions. By focusing on a group of non-elite personnel, namely, constables, assessors, collectors, supervisors and searchers in Norwich between 1414 and 1473, this paper demonstrates the essential role played by such individuals and postulates that not all urban office-holders nursed greater ambitions.
The fact that the plague in its bubonic, septicaemic and pneumonic forms is still with us in the twenty-first century often comes as a shock to the general public. Memories of school projects have made them vaguely aware of the great pandemic, which arrived in southern Italy in 1347 and then raged across Europe, reaching England and Norway in 1348, through Oslo in 1348 and then through Bergen in 1349, and European Russia in 1351, where the city state of Novgorod was first infected. But then, surely, it went away? Not quite: outbreaks of plague in this second pandemic, first (allegedly) called the Black Death by Mrs Markham in 1823 in her History of England, from which the horrors of history and the complexities of party politics were removed as not suitable for young minds, lasted in England until the early eighteenth century, whilst in Italy what is generally regarded as its final appearance came at Naja, near Bari, in 1815. Even then the disease did not disappear. It merely became dormant until 1855, when a new pandemic began in China, spreading through the Pacific Rim and in 1899 to the United States where plague had previously been unknown. Indeed, as the well-known World Health Organisation map of plague loci and plague outbreaks 1970–1998 shows, the disease is enzootic or sylvatic (ever-present in certain animal populations and their fleas) in some fifty-eight different regions in the world and can still spread to more susceptible animals, including humans, in epizootic outbreaks.
Described as "a golden age of pathogens", the long fifteenth century was notable for a series of international, national and regional epidemics that had a profound effect upon the fabric of society. The impact of pestilence upon the literary, religious, social and political life of men, women and children throughout Europe and beyond continues to excite lively debate among historians, as the ten papers presented in this volume confirm. They deal with the response of urban communities in England, France and Italy to matters of public health, governance and welfare, as well as addressing the reactions of the medical profession to successive outbreaks of disease, and of individuals to the omnipresence of Death, while two, very different, essays examine the important, if sometimes controversial, contribution now being made by microbiologists to our understanding of the Black Death. Contributors: J.L. Bolton, Elma Brenner, Samuel Cohn, John Henderson, Neil Murphy, Elizabeth Rutledge, Samantha Sagui, Karen Smyth, Jane Stevens Crawshaw, Sheila Sweetinburgh