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At its late Pleistocene maximum, the Laurentide Ice Sheet was the largest ice mass on Earth and a key player in the modulation of global climate and sea level. At the same time, this temperate ice sheet was itself sensitive to climate, and high-magnitude fluctuations in ice extent, reconstructed from relict glacial deposits, reflect past changes in atmospheric temperature. Here, we present a cosmogenic 10Be surface-exposure chronology for the Berlin moraines in the White Mountains of northern New Hampshire, USA, which supports the model that deglaciation of New England was interrupted by a pronounced advance of ice during the Bølling-Allerød. Together with recalculated 10Be ages from the southern New England coast, the expanded White Mountains moraine chronology also brackets the timing of ice sheet retreat in this sector of the Laurentide. In conjunction with existing chronological data, the moraine ages presented here suggest that deglaciation was widespread during Heinrich Stadial 1 event (~18–14.7 ka) despite apparently cold marine conditions in the adjacent North Atlantic. As part of the White Mountains moraine system, the Berlin chronology also places a new terrestrial constraint on the former glacial configuration during the marine incursion of the St. Lawrence River valley north of the White Mountains.
Self-reported activity restriction is an established correlate of depression in dementia caregivers (dCGs). It is plausible that the daily distribution of objectively measured activity is also altered in dCGs with depression symptoms; if so, such activity characteristics could provide a passively measurable marker of depression or specific times to target preventive interventions. We therefore investigated how levels of activity throughout the day differed in dCGs with and without depression symptoms, then tested whether any such differences predicted changes in symptoms 6 months later.
Design, setting, participants, and measurements:
We examined 56 dCGs (mean age = 71, standard deviation (SD) = 6.7; 68% female) and used clustering to identify subgroups which had distinct depression symptom levels, leveraging baseline Center for Epidemiologic Studies of Depression Scale–Revised Edition and Patient Health Questionnaire-9 (PHQ-9) measures, as well as a PHQ-9 score from 6 months later. Using wrist activity (mean recording length = 12.9 days, minimum = 6 days), we calculated average hourly activity levels and then assessed when activity levels relate to depression symptoms and changes in symptoms 6 months later.
Clustering identified subgroups characterized by: (1) no/minimal symptoms (36%) and (2) depression symptoms (64%). After multiple comparison correction, the group of dCGs with depression symptoms was less active from 8 to 10 AM (Cohen’s d ≤ −0.9). These morning activity levels predicted the degree of symptom change on the PHQ-9 6 months later (per SD unit β = −0.8, 95% confidence interval: −1.6, −0.1, p = 0.03) independent of self-reported activity restriction and other key factors.
These novel findings suggest that morning activity may protect dCGs from depression symptoms. Future studies should test whether helping dCGs get active in the morning influences the other features of depression in this population (i.e. insomnia, intrusive thoughts, and perceived activity restriction).
“Structural violence” is a term used to describe inflicted systematic violence on a disenfranchised group by an established order, usually framed as a government or the social majority. The disenfranchised groups are marginalized and not provided with the same access to resources such as healthcare or food, the effects of which can be observed directly in their death. Bioarchaeologists often can detect the visible effects of this violence on skeletal remains, which provide a visual representation to and reinforcement of social prejudices inflicted in life and death. Discussed here is how the same concept of structural violence can be inflicted on the landscape through damage to or obliteration of cemeteries. We propose a definition of “landscape structural violence” exhibited through cemetery erasure as a reinforcement of preexisting social prejudices in death where the governments or the social majority, intentionally or passively, destroy, remove, or obscure a cemetery without consultation with the descendant community. This definition is applied to several examples of New Orleans cemeteries to determine the functionality of the definition and what activity is and what is not structural violence inflicted on the landscape.
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.
From the early days of European settlement in North America, Christianity has had a profound impact on American law and culture. This volume profiles nineteen of America's most influential Christian jurists from the early colonial era to the present day. Anyone interested in American legal history and jurisprudence, the role Christianity has played throughout the nation's history, and the relationship between faith and law will enjoy this worthy and unique study. The jurists covered in this collection were pious men and women, but that does not mean they agreed on how faith should inform law. From Roger Williams and John Cotton to Antonin Scalia and Mary Ann Glendon, America's great Christian jurists have brought their faith to bear on the practice of law in different ways and to different effects.
To describe low-income parents’ and caregivers’ perceptions of the Cooking Matters Mobile Application (CM App) meal planning and preparation features.
Explanatory mixed-methods design where data were gathered via online surveys based on the Theory of Planned Behaviour and the Theory of Reasoned Action, followed by telephone interviews.
CM App, a mobile phone-based resource geared towards low-income parents and caregivers of young children (pregnancy/infant to age 5 years) for meal planning and preparation, with features based on skills taught in the Cooking Matters course: recipes, shopping list and meal planning.
Low-income parents and caregivers (survey participants, n 461; interview participants, n 20) who had downloaded the CM App to their smartphone and agreed to participate in the current evaluation.
Attitudes and self-efficacy related to CM App’s subject matter and functions (meal planning; recipe use; creating and using a shopping list) were measured via surveys and interviews. Mean (sd) responses were positive towards ‘meal planning’ and ‘shopping and cooking’ (4·17 (0·63) and 3·49 (0·86) on a 5-point Likert scale, respectively). Interviewees described meal planning and preparation behaviours as intrinsic, based on habit, and influenced by family preference and food costs. Early adopters of the CM App may already be engaged in and/or are motivated to engage in the targeted health behaviours.
Users may benefit most from incorporating into their routines new ways to prepare easy, cost-efficient, healthy meals at home that their families will enjoy.
Introduction: Clinicians treating children in the emergency department (ED) are especially concerned with the efficacy and safety of imaging. Interventions to limit imaging have been proposed to maximize benefits and avoid risks; however, the types and effectiveness of interventions employed in pediatric EDs have not been examined in detail. Methods: Electronic databases and grey literature were systematically searched by a medical librarian. Comparative studies of ED-based interventions reporting computed tomography (CT), radiography (XR), or ultrasound (US) outcomes were included. Interventions introducing new imaging equipment or personnel to the ED, ED diversion strategies, and pre-admission protocols were excluded. At least two independent reviewers assessed each study for inclusion based on pre-defined criteria and extracted data. Disagreements were resolved through consensus. Descriptive results are reported. Results: Overall, 38 pediatric studies were included. Most (66%) interventions implemented two or more components; the most common intervention components were clinical guidelines or pathways (87%) and education or information (66%). Studies were categorized by presentation type: traumatic (n = 27); non-traumatic (n = 19), or combined ‘all-comers’ (n = 2). Included studies reported 62 imaging outcomes (CT = 29; XR = 20; US = 13). Among traumatic studies, 26 imaging outcomes were reported; CT was the most commonly reported outcome (CT = 15; XR = 9; US = 1). Of the CT outcomes, 33% reported significant decreases and five decreased but were either not significant or did not report significance. XR significantly decreased in 44% (4/9). In the non-traumatic studies, the most common imaging outcome remained CT (12 outcomes); 58% of which reported significant decreases. XR was the second most frequent outcome, with 63% reporting significant reductions. Combined success of the interventions to reduce CT and XR was 60%. Reported changes in ordering were less consistent in US. Conclusion: Multifaceted passive interventions have been implemented to reduce imaging in pediatric EDs. Most reported some success changing ordering practices, specifically among patients with non-trauma presentations. Future research exploring relationships between intervention content, effectiveness, and fidelity may provide insight into how to develop more effective interventions to change image ordering in the ED and guide which presentations to target.
Introduction: Competency-based medical education (CBME) relies on pragmatic assessment to inform trainee progression decisions. It is unclear whether face-to-face workplace-based assessment (WBA) scoring by faculty reflects their true perception of trainee competence, as many factors influence individual assessments. To better defend competence committee decisions, it is critical to understand how accurately WBAs reflect the faculty's honest perception of resident competence and entrustment. Methods: To best capture faculty perception of trainee competence, we created a periodic performance assessment (PPA) tool for anonymous faculty assessment of residents after repeated clinical interactions. PPA surveys were distributed to full-time EM faculty at a single Canadian FRCPC-EM training site. Faculty were asked to score residents on entrustable professional activities (EPAs) based on encounters over the previous 6-months, and were advised that all data would be anonymized. All WBA scores for FRCPC-EM residents (N = 21) were collected from the 6-months preceding PPA completion. Analysis compared paired WBA and PPA entrustment scores for an individual resident, faculty, and EPA using Wilcoxon Signed Ranks tests and Spearman correlations. Data were analyzed across faculty, EPAs, and both faculty and EPA. Results: About half (17/33) of all invited full-time EM faculty participated. Overall, anonymous PPAs had a significantly lower mean score compared to face-to-face WBAs (3.61-3.69 vs. 3.92-4.06, p < 0.001 for all) across all groupings. Individual WBAs had a low-moderate correlation with individual PPAs (rho = 0.44). When scores were averaged across 1) faculty or 2) EPA, there was an increase in correlation, but it remained moderate (rho = 0.53 and 0.54, respectively). When scores were averaged for an individual resident across 3) faculty and EPA, there was a strong correlation between WBA and PPA (rho = 0.86). Conclusion: There is only moderate correlation between an individual faculty's WBAs and their anonymous longitudinal entrustment for a given resident on a specific EPA. These results may signal caution when interpreting WBA scores in the context of high stakes decisions. Aggregated scores from multiple faculty and/or multiple EPAs substantially increased the correlation between WBA and PPA. These findings highlight the importance of using aggregated WBA scores across multiple assessors and EPA for high-stakes resident progression decisions, to minimize the noise and bias in individual assessment.
Introduction: Quality improvement and patient safety (QIPS) are increasingly recognized as integral to the provision and advancement of emergency medicine (EM) care. In 2015, QIPS were added to the Canadian Medical Education Directives for Specialists (CanMEDS) framework. However, the level of QIPS education and support that Canadian EM residents receive is unknown. In order to better plan national QIPS efforts aimed at enabling EM residents to improve their local care settings, we sought to assess the current state of QIPS education and support in Canadian EM residency programs. Methods: This was a descriptive, cross-sectional electronic survey that was disseminated to all current Canadian EM residents from both Royal College (RC) and Family Medicine - EM training streams. Residents were recruited either directly or through their program's administrative assistant. The survey consisted of multiple-choice, Likert and free-text entry questions. Themes included a) familiarity with QIPS; b) local opportunities for QIPS projects and mentorship; and c) desire for further QIPS education and involvement. The survey was open for a five-week period, with formal reminders after the first and third weeks. Descriptive statistics are reported. Results: 189 (35%) of 535 current EM residents completed the survey, representing all 17 medical schools. 77% of respondents were from the RC stream. 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS. 47.2% of respondents reported “not knowing” or “not having readily available” QIPS projects to participate in their local environment, and 51.5% had equivalent responses with respect to QIPS mentorship opportunities. Only 17.5% of respondents reported that QIPS methodologies were already formally taught in their residency program, and 66.9% indicated a desire for increased QIPS teaching. The majority of respondents were “slightly” (35.9%), “moderately” (23.2%) or “very” (11.3%) interested in becoming involved with QIPS training and initiatives. Conclusion: Responding Canadian EM residents are interested in obtaining greater QIPS education as well as project and mentorship opportunities, but many perceive that they do not have adequate access to these at the current time. As the importance of QIPS increases in the EM community, supporting residents with more robust educational infrastructures may be necessary. Future efforts may include the standardizing of QIPS postgraduate curricula and improving access to QIPS opportunities across the country.
To ascertain opinions regarding etiology and preventability of hospital-onset bacteremia and fungemia (HOB) and perspectives on HOB as a potential outcome measure reflecting quality of infection prevention and hospital care.
Hospital epidemiologists and infection preventionist members of the Society for Healthcare Epidemiology of America (SHEA) Research Network.
A web-based, multiple-choice survey was administered via the SHEA Research Network to 133 hospitals.
A total of 89 surveys were completed (67% response rate). Overall, 60% of respondents defined HOB as a positive blood culture on or after hospital day 3. Central line-associated bloodstream infections and intra-abdominal infections were perceived as the most frequent etiologies. Moreover, 61% thought that most HOB events are preventable, and 54% viewed HOB as a measure reflecting a hospital’s quality of care. Also, 29% of respondents’ hospitals already collect HOB data for internal purposes. Given a choice to publicly report central-line–associated bloodstream infections (CLABSIs) and/or HOB, 57% favored reporting either HOB alone (22%) or in addition to CLABSI (35%) and 34% favored CLABSI alone.
Among the majority of SHEA Research Network respondents, HOB is perceived as preventable, reflective of quality of care, and potentially acceptable as a publicly reported quality metric. Further studies on HOB are needed, including validation as a quality measure, assessment of risk adjustment, and formation of evidence-based bundles and toolkits to facilitate measurement and improvement of HOB rates.
Shiga-toxin producing Escherichia coli (STEC) is a pathogen that can cause bloody diarrhoea and severe complications. Cases occur sporadically but outbreaks are also common. Understanding the incubation period distribution and factors influencing it will help in the investigation of exposures and consequent disease control. We extracted individual patient data for STEC cases associated with outbreaks with a known source of exposure in England and Wales. The incubation period was derived and cases were described according to patient and outbreak characteristics. We tested for heterogeneity in reported incubation period between outbreaks and described the pattern of heterogeneity. We employed a multi-level regression model to examine the relationship between patient characteristics such as age, gender and reported symptoms; and outbreak characteristics such as mode of transmission with the incubation period. A total of 205 cases from 41 outbreaks were included in the study, of which 64 cases (31%) were from a single outbreak. The median incubation period was 4 days. Cases reporting bloody diarrhoea reported shorter incubation periods compared with cases without bloody diarrhoea, and likewise, cases aged between 40 and 59 years reported shorter incubation period compared with other age groups. It is recommended that public health officials consider the characteristics of cases involved in an outbreak in order to inform the outbreak investigation and the period of exposure to be investigated.
The short-term impact of prolonged grief disorder (PGD) following bereavement is well documented. The longer term sequelae of PGD however are poorly understood, possibly unrecognized, and may be incorrectly attributed to other mental health disorders and hence undertreated.
The aims of this study were to prospectively evaluate the prevalence of PGD three years post bereavement and to examine the predictors of long-term PGD in a population-based cohort of bereaved cancer caregivers.
A cohort of primary family caregivers of patients admitted to one of three palliative care services in Melbourne, Australia, participated in the study (n = 301). Sociodemographic, mental health, and bereavement-related data were collected from the caregiver upon the patient's admission to palliative care (T1). Further data addressing circumstances around the death and psychological health were collected at six (T2, n = 167), 13 (T3, n = 143), and 37 months (T4, n = 85) after bereavement.
At T4, 5% and 14% of bereaved caregivers met criteria for PGD and subthreshold PGD, respectively. Applying the total PGD score at T4, linear regression analysis found preloss anticipatory grief measured at T1 and self-reported coping measured at T2 were highly statistically significant predictors (both p < 0.0001) of PGD in the longer term.
For almost 20% of caregivers, the symptoms of PGD appear to persist at least three years post bereavement. These findings support the importance of screening caregivers upon the patient's admission to palliative care and at six months after bereavement to ascertain their current mental health. Ideally, caregivers at risk of developing PGD can be identified and treated before PGD becomes entrenched.
In the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers.
We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason.
We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = −0.71; 95% confidence interval [CI] −1.01 to −0.41; I2 = 83%; 95% CI 78–88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = −1.02; 95% CI −1.52 to −0.51; I2 = 89%; 95% CI 82–93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = −1.05; 95% CI −1.55 to −0.56; I2 = 87%; 95% CI 79–92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life.
Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.