Book chapters will be unavailable on Saturday 24th August between 8am-12pm BST. This is for essential maintenance which will provide improved performance going forwards. Please accept our apologies for any inconvenience caused.
To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Warwick Heale has recently defended the notion of individualized and personalized Quality-Adjusted Life Years (QALYs) in connection with health care resource allocation decisions. Ordinarily, QALYs are used to make allocation decisions at the population level. If a health care intervention costs £100,000 and generally yields only two years of survival, the cost per QALY gained will be £50,000, far in excess of the £30,000 limit per QALY judged an acceptable use of resources within the National Health Service in the United Kingdom. However, if we know with medical certainty that a patient will gain four extra years of life from that intervention, the cost per QALY will be £25,000. Heale argues fairness and social utility require such a patient to receive that treatment, even though all others in the cohort of that patient might be denied that treatment (and lose two years of potential life). Likewise, Heale argues that personal commitments of an individual (religious or otherwise), that determine how they value a life-year with some medical intervention, ought to be used to determine the value of a QALY for them. I argue that if Heale’s proposals were put into practice, the result would often be greater injustice. In brief, requirements for the just allocation of health care resources are more complex than pure cost-effectiveness analysis would allow.
Acceptance and commitment therapy (ACT) is a psychological treatment that has been found to increase weight loss in adults when combined with lifestyle modification, compared with the latter treatment alone. However, an ACT-based treatment for weight loss has never been tested in adolescents.
The present pilot study assessed the feasibility and acceptability of a 16-week, group ACT-based lifestyle modification treatment for adolescents and their parents/guardians. The co-primary outcomes were: (1) mean acceptability scores from up to 8 biweekly ratings; and (2) the percentage reduction in body mass index (BMI) from baseline to week 16. The effect size for changes in cardiometabolic and psychosocial outcomes from baseline to week 16 also was examined.
Seven families enrolled and six completed treatment (14.3% attrition). The mean acceptability score was 8.8 for adolescents and 9.0 for parents (on a 1–10 scale), indicating high acceptability. The six adolescents who completed treatment experienced a 1.3% reduction in BMI (SD = 2.3, d = 0.54). They reported a medium increase in cognitive restraint, a small reduction in hunger, and a small increase in physical activity. They experienced small improvements in most quality of life domains and a large reduction in depression.
These preliminary findings indicate that ACT plus lifestyle modification was a highly acceptable treatment that improved weight, cognitive restraint, hunger, physical activity, and psychosocial outcomes in adolescents with obesity.
The present study evaluates the use of multiple correspondence analysis (MCA), a type of exploratory factor analysis designed to reduce the dimensionality of large categorical data sets, in identifying behaviours associated with measures of overweight/obesity in Vanuatu, a rapidly modernizing Pacific Island country.
Starting with seventy-three true/false questions regarding a variety of behaviours, MCA identified twelve most significantly associated with modernization status and transformed the aggregate binary responses of participants to these twelve questions into a linear scale. Using this scale, individuals were separated into three modernization groups (tertiles) among which measures of body fat were compared and OR for overweight/obesity were computed.
Ni-Vanuatu adults (n 810) aged 20–85 years.
Among individuals in the tertile characterized by positive responses to most of or all the twelve modernization questions, weight and measures of body fat and the likelihood that measures of body fat were above the US 75th percentile were significantly greater compared with individuals in the tertiles characterized by mostly or partly negative responses.
The study indicates that MCA can be used to identify individuals or groups at risk for overweight/obesity, based on answers to simply-put questions. MCA therefore may be useful in areas where obtaining detailed information about modernization status is constrained by time, money or manpower.
Many a secret that cannot be pried out by curiosity can be drawn out by indifference.
Sidney J. Harris
Lack of information is generally considered a hindrance to inquiry. Surprisingly, a simple mathematical argument, relying on the Principle of Indifference, shows there are situations where the opposite holds. Even more surprisingly, this indifference allows one to guess, with a success rate greater than 50%, the outcome of a coin toss or any other experiment having two equiprobable outcomes. The scheme is based on work by American statistician David Blackwell (1919–2010) and a principle of mathematical probability attributed to Swiss mathematician Jakob Bernoulli (1655–1705).
Background: Scrupulosity is a common yet understudied presentation of obsessive compulsive disorder (OCD) that is characterized by obsessions and compulsions focused on religion. Despite the clinical relevance of scrupulosity to some presentations of OCD, little is known about the association between scrupulosity and symptom severity across religious groups. Aims: The present study examined the relationship between (a) religious affiliation and OCD symptoms, (b) religious affiliation and scrupulosity, and (c) scrupulosity and OCD symptoms across religious affiliations. Method: One-way ANOVAs, Pearson correlations and regression-based moderation analyses were conducted to evaluate these relationships in 180 treatment-seeking adults with OCD who completed measures of scrupulosity and OCD symptom severity. Results: Scrupulosity, but not OCD symptoms in general, differed across religious affiliations. Individuals who identified as Catholic reported the highest level of scrupulosity relative to individuals who identified as Protestant, Jewish or having no religion. Scrupulosity was associated with OCD symptom severity globally and across symptom dimensions, and the magnitude of these relationships differed by religious affiliation. Conclusions: Findings are discussed in terms of the dimensionality of scrupulosity, need for further assessment instruments, implications for assessment and intervention, and the consideration of religious identity in treatment.
Meeting healthcare needs is a matter of social justice. Healthcare needs are virtually limitless; however, resources, such as money, for meeting those needs, are limited. How then should we (just and caring citizens and policymakers in such a society) decide which needs must be met as a matter of justice with those limited resources? One reasonable response would be that we should use cost effectiveness as our primary criterion for making those choices. This article argues instead that cost-effectiveness considerations must be constrained by considerations of healthcare justice. The goal of this article will be to provide a preliminary account of how we might distinguish just from unjust or insufficiently just applications of cost-effectiveness analysis to some healthcare rationing problems; specifically, problems related to extraordinarily expensive targeted cancer therapies. Unconstrained compassionate appeals for resources for the medically least well-off cancer patients will be neither just nor cost effective.
The aim of this study was to explore the support needs of Dutch informal caregivers of patients with amyotrophic lateral sclerosis (ALS).
Individual semi-structured interviews were conducted with 21 caregivers of ALS patients. Audio-taped interviews were transcribed and data were analyzed thematically.
A total of four global support needs emerged: “more personal time”, “assistance in applying for resources”, “counseling”, and “peer contact”. Despite their needs, caregivers are reluctant to apply for and accept support. They saw their own needs as secondary to the needs of the patients.
Significance of results
ALS seems to lead to an intensive caregiving situation with multiple needs emerging in a short period. This study offers targets for the development of supportive interventions. A proactive approach seems essential, acknowledging the importance of the role of the caregivers in the care process at an early stage, informing them about the risk of burden, monitoring their wellbeing, and repeatedly offering support opportunities. Using e-health may help tailor interventions to the caregivers’ support needs.
Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes.
Violators of cooperation norms may be informally punished by their peers. How such norm enforcement is judged by others can be regarded as a meta-norm (i.e., a second-order norm). We examined whether meta-norms about peer punishment vary across cultures by having students in eight countries judge animations in which an agent who over-harvested a common resource was punished either by a single peer or by the entire peer group. Whether the punishment was retributive or restorative varied between two studies, and findings were largely consistent across these two types of punishment. Across all countries, punishment was judged as more appropriate when implemented by the entire peer group than by an individual. Differences between countries were revealed in judgments of punishers vs. non-punishers. Specifically, appraisals of punishers were relatively negative in three Western countries and Japan, and more neutral in Pakistan, UAE, Russia, and China, consistent with the influence of individualism, power distance, and/or indulgence. Our studies constitute a first step in mapping how meta-norms vary around the globe, demonstrating both cultural universals and cultural differences.
A 14 year kinematic survey of Spruce Creek rock glacier, Colorado, USA, provides information on rates and controls of surface strain. Steel-tape measurements of differential movement yield data of cm-scale accuracy, sufficient to assess strain patterns over small portions of the very slowly deforming rock glacier. Flow rates are typically <10cma–1, and measured strain rates range from 1.0 × 10–5a–1 to 1.5 × 10–3a–1. The primary control on longitudinal strain is changing surface slope, with extending flow occurring in areas of down-valley increase in slope, and compressing flow in areas of down-valley slope decrease. Relatively high strain rates are associated with higher flow velocities and with the impingement of faster-flowing up-valley portions of the rock glacier on the slower-moving lower portion. Overall strain rates decreased through the study period, probably as a result of a slowing of the upper part of the rock glacier. Transverse ridges are associated with longitudinal shortening, caused by either slope changes or impingement of faster-moving sections of the rock glacier on slower-moving sections, but transverse ridges do not occur in every area of strong longitudinal shortening.
Buried surface hoar and near-surface faceted crystals are known to lead to deadly avalanches. Over the course of three winter seasons a field investigation detailing the environmental conditions leading to the formation of these crystals was performed. Weather stations on north- and south-facing aspects were established. The weather data were accompanied by detailed daily observations and grain-scale photographs of the snow surface. During the three seasons, 35 surface hoar and 47 near-surface facets events were recorded. The mean weather conditions for the entire dataset (all three seasons and both stations) were compared to the nights when surface hoar formed. The comparison yielded five parameters that were statistically linked to the formation of surface hoar: incoming longwave radiation, snow surface temperature, wind velocity, relative humidity and the air/snow temperature difference. A similar comparison between the daytime mean values for all days with near-surface facet events revealed three parameters with statistically significant differences. Thus, these parameters (short- and longwave radiation and relative humidity) could be statistically linked to facet formation. This research also suggests that environmental conditions in the daytime hours before and after surface hoar formation are statistically similar to the conditions causing near-surface facet formation.
A distinctive feature of polar regions is the formation of ice clusters attached to the seabed, known as ‘anchor ice’. Anchor ice plays an important role in mobilizing bed sediments, and serves ecological roles providing habitats, or as an agent of disturbance creating potentially fatal environments to benthic fauna. The sublittoral zone associated with the landward margin represents the most likely environment for anchor ice formation, where conditions conducive to the advection of supercooled water from sub-ice-shelf cavities are favourable. We develop a framework to estimate the areal extent of anchor ice formation assuming a northerly flow of 75m deep supercooled water plumes from the Ross and McMurdo Ice Shelf cavities, Antarctica. In McMurdo Sound our results indicate that regions beneath the McMurdo Ice Shelf, extending along Brown Peninsula and White and Black Islands, are likely conducive to anchor ice formation. Anchor ice may also form along the Hut Point Peninsula and around Ross Island, and in pockets along the southern Victoria Land coast. The limitations of our approach include an imposed northerly flow of Ice Shelf Water, poorly constrained sub-ice-shelf bathymetry, and temporal variability in supercooled water depth production, particularly in the eastern Sound.
Depression and metabolic syndrome (MetS) are frequently comorbid disorders that are independently associated with premature mortality. Conversely, cardiorespiratory fitness (CRF) is associated with reduced mortality risk. These factors may interact to impact mortality; however, their effects have not been assessed concurrently. This analysis assessed the mortality risk of comorbid depression/MetS and the effect of CRF on mortality in those with depression/MetS.
Prospective study of 47 702 adults in the Cooper Center Longitudinal Study. Mortality status was attained from the National Death Index. History of depression was determined by patient response (yes or no) to a standardized medical history questionnaire. MetS was categorized using the American Heart Association/National Heart, Lung, and Blood Institute criteria. CRF was estimated from the final speed/grade of a treadmill graded exercise test.
13.9% reported a history of depression, 21.4% met criteria for MetS, and 3.0% met criteria for both MetS and history of depression. History of depression (HR = 1.24, p = 0.003) and MetS (HR = 1.28, p < 0.001) were independently associated with an increased mortality risk, with the greatest mortality risk among individuals with both a history of depression and MetS (HR = 1.59, p < 0.001). Higher CRF was associated with a significantly lower risk of mortality (p < 0.001) in all individuals, including those with MetS and/or a history of depression.
Those with higher levels CRF had reduced mortality risk in the context of depression/MetS. Interventions that improve CRF could have substantial impact on the health of persons with depression/MetS.
To assess resource allocation and costs associated with US hospitals preparing for the possible spread of the 2014–2015 Ebola virus disease (EVD) epidemic in the United States.
A survey was sent to a stratified national probability sample (n=750) of US general medical/surgical hospitals selected from the American Hospital Association (AHA) list of hospitals. The survey was also sent to all children’s general hospitals listed by the AHA (n=60). The survey assessed EVD preparation supply costs and overtime staff hours. The average national wage was multiplied by labor hours to calculate overtime labor costs. Additional information collected included challenges, benefits, and perceived value of EVD preparedness activities.
The average amount spent by hospitals on combined supply and overtime labor costs was $80,461 (n=133; 95% confidence interval [CI], $56,502–$104,419). Multivariate analysis indicated that small hospitals (mean, $76,167) spent more on staff overtime costs per 100 beds than large hospitals (mean, $15,737; P<.0001). The overall cost for acute-care hospitals in the United States to prepare for possible EVD cases was estimated to be $361,108,968. The leading challenge was difficulty obtaining supplies from vendors due to shortages (83%; 95% CI, 78%–88%) and the greatest benefit was improved knowledge about personal protective equipment (89%; 95% CI, 85%–93%).
The financial impact of EVD preparedness activities was substantial. Overtime cost in smaller hospitals was >3 times that in larger hospitals. Planning for emerging infectious disease identification, triage, and management should be conducted at regional and national levels in the United States to facilitate efficient and appropriate allocation of resources in acute-care facilities.
The study of ice in the upper Great Lakes, both from the operational and the scientific points of view, is receiving continued attention. Both quantitative and qualitative field work is being conducted to provide the needed background for accurate interpretation of remotely sensed data. The sensor data under discussion in this paper were obtained by a side-looking multiplexed airborne radar (SLAR). These were supplemented with ground-truth data.
Radar, due to its ability to penetrate adverse weather, is an especially important instrument for monitoring ice in the upper Great Lakes. It has been previously shown that imaging radars can provide maps of ice cover in these areas. However, questions concerning both the nature of the surfaces reflecting radar energy and the interpretation of the radar imagery continually arise.
Our analysis office in Whitefish Bay (Lake Superior) indicated that the combination of the ice/water interface with the ice/air interface is the major contributor to the radar backscatter as seen on the imagery. The ice has a very low dielectric constant (<3.0) and a low loss tangent. Thus, this ice is somewhat transparent to the energy used by the imaging SLAR system. The ice types studied include newly formed black ice, pancake ice, and frozen and consolidated pack and brash ice.
Although ice thickness cannot be measured directly from the received signals, it is suspected that by combining the radar backscatter information with both meteorological and sea-state history of the area and with some basic ground truth, better estimates of the ice thickness may be provided. In addition, certain ice features (e.g. ridges, ice foots, areas of brash ice) may be identified with reasonable confidence. There is a continued need for additional ground work to verify the validity of imaging radars for these types of interpretations.
This paper is being published in full in another issue of the Journal of Glaciology.