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.
There is a continual need for invasive plant science to develop approaches for cost-effectively benefiting native over non-native species in dynamic management and biophysical contexts, including within predominately non-native plant landscapes containing only small patches of native plants. Our objective was to test effectiveness of a minimal-input strategy for enlarging native species patches within a non-native plant matrix. In Pecos National Historical Park, New Mexico, USA, we identified 40 native perennial grass patches within a matrix of the non-native annual forb kochia (Bassia scoparia (L.) A.J. Scott). We mechanically cut B. scoparia in a 2-m-wide ring surrounding the perimeters of half the native grass patches (with the other half as uncut controls) and measured change in native grass patch size (relative to pre-treatment) for three years. Native grass patches around which B. scoparia was cut grew quickly the first post-treatment year, and by the third year, had increased in size 4× more than control patches. Treated native grass patches expanded by an average of 25 m2, from 4 m2 in October 2015 before treatment to 29 m2 in October 2018. The experiment occurred during a dry period, conditions that should favor B. scoparia and contraction of the native grasses, suggesting that the observed increase in native grasses occurred despite suboptimal climatic conditions. Strategically treating around native patches to enlarge them over time showed promise as a minimal-input technique for increasing the proportion of the landscape dominated by native plants.
Whole apples are a source of pectin and polyphenols, both of which show potential to modulate postprandial lipaemia (PPL). The present study aimed to explore the effects of whole apple consumption on PPL, as a risk factor for CVD, in generally healthy but overweight and obese adults. A randomised, crossover acute meal trial was conducted with seventeen women and nine men (mean BMI of 34·1 (sem 0·2) kg/m2). Blood samples were collected for 6 h after participants consumed an oral fat tolerance test meal that provided 1 g fat/kg body weight and 1500 mg acetaminophen per meal for estimating gastric emptying, with and without three whole raw Gala apples (approximately 200 g). Plasma TAG (with peak postprandial concentration as the primary outcome), apoB48, chylomicron-rich fraction particle size and fatty acid composition, glucose, insulin and acetaminophen were analysed. Differences between with and without apples were identified by ANCOVA. Apple consumption did not alter postprandial TAG response, chylomicron properties, glucose or acetaminophen (P > 0·05), but did lead to a higher apoB48 peak concentration and exaggerated insulin between 20 and 180 min (P < 0·05). Overall, as a complex food matrix, apples did not modulate postprandial TAG when consumed with a high-fat meal in overweight and obese adults, but did stimulate insulin secretion, potentially contributing to an increased TAG-rich lipoprotein production.
Children from language minority (LM) environments speak a language at home that differs from that at school, are often from socioeconomically disadvantaged backgrounds, and are at risk for reading impairment. We evaluated the main effects and interaction of language status and phonological memory and awareness on reading disorder in 352 children from socioeconomically disadvantaged backgrounds. A significant phonological memory by language status interaction indicated that phonological memory problems were magnified in predicting reading impairment in children from LM versus English dominant (ED) homes. Among children without reading disorder, language minority status was unrelated to phonological processing.
Extremely low birth weight (ELBW) survivors have higher rates of shyness, a risk factor for poorer outcomes across the life span. Due to advances in fetal and neonatal medicine, the first generation of ELBW survivors have survived to adulthood and become parents. However, no studies have investigated the transmission of their stress vulnerability to their offspring. We explored this phenomenon using a population-based cohort of ELBW survivors and normal birth weight (NBW) controls. Using data from three generations, we examined whether the shyness and parenting stress of ELBW and NBW participants (Generation 2) mediated the relation between the parenting style of their parents (Generation 1) and shyness in their offspring (Generation 3), and the extent to which exposure to perinatal adversity (Generation 2) moderated this mediating effect. We found that among ELBW survivors, parenting stress (in Generation 2) mediated the relation between overprotective parenting style in Generation 1 (grandparents) and child shyness in Generation 3. These findings suggest that perinatal adversity and stress may be transmitted to the next generation in humans, as reflected in their perceptions of their children as shy and socially anxious, a personality phenotype that may subsequently place their children at risk of later mental and physical health problems.
We conducted active surveillance of acute respiratory viral infections (ARIs) among residents and healthcare personnel (HCP) at a long-term care facility during the 2015–2016 respiratory illness season. ARIs were observed among both HCP and patients, highlighting the importance of including HCP in surveillance programs.
To assess the feasibility, reliability, and validity of the Pictorial Fit-Frail Scale (PFFS) among patients, caregivers, nurses, and geriatricians in an outpatient memory clinic.
A Canadian referral-based outpatient memory clinic.
Fifty-one consecutive patients and/or their caregivers, as well as attending nurses and geriatricians.
Participants (patients, caregivers, nurses, and geriatricians) were asked to complete the PFFS based on the patient’s current level of functioning. Time-to-complete and level of assistance required was recorded. Participants also completed a demographic survey and patients’ medical history (including the Mini-Mental State Examination [MMSE], and Comprehensive Geriatric Assessment [CGA]) was obtained via chart review.
Patient participants had a mean age of 77.3±10.1 years, and average MMSE of 22.0±7.0, and 53% were female. Participants were able to complete the PFFS with minimal assistance, and their average times to completion were 4:38±2:09, 3:11±1:16, 1:05±0:19, and 0:57±0:30 (mins:sec) for patients, caregivers, nurses, and geriatricians, respectively. Mean PFFS scores as rated by patients, caregivers, nurses, and geriatricians were 9.0±5.7, 13.1±6.6, 11.2±4.5, 11.9±5.9, respectively. Patients with low MMSE scores (0–24) took significantly longer to complete the scale and had higher PFFS scores. Inter-rater reliability between nurses and geriatricians was 0.74, but it was lower when assessments were done for patients with low MMSE scores (0.47, p<0.05). The correlation between PFFS and a Frailty Index based on the CGA was moderately high and statistically significant for caregivers, nurses, and geriatricians (r=0.66, r=0.59, r=0.64, respectively), but not patients.
The PFFS is feasible, even among people with some slight cognitive impairment, though it may be less useful when patients with severe dementia administer it to themselves. Further, the PFFS may help inform clinicians about areas of concern as identified by patients, enabling them to contribute more to diagnostic and treatment decisions or helping with health tracking and care planning.
The primary objective of this study was to examine the impact of an electronic medical record (EMR)–driven intensive care unit (ICU) antimicrobial stewardship (AMS) service on clinician compliance with face-to-face AMS recommendations. AMS recommendations were defined by an internally developed “5 Moments of Antimicrobial Prescribing” metric: (1) escalation, (2) de-escalation, (3) discontinuation, (4) switch, and (5) optimization. The secondary objectives included measuring the impact of this service on (1) antibiotic appropriateness, and (2) use of high-priority target antimicrobials.
A prospective review was undertaken of the implementation and compliance with a new ICU-AMS service that utilized EMR data coupled with face-to-face recommendations. Additional patient data were collected when an AMS recommendation was made. The impact of the ICU-AMS round on antimicrobial appropriateness was evaluated using point-prevalence survey data.
For the 202 patients, 412 recommendations were made in accordance with the “5 Moments” metric. The most common recommendation made by the ICU-AMS team was moment 3 (discontinuation), which comprised 173 of 412 recommendations (42.0%), with an acceptance rate of 83.8% (145 of 173). Data collected for point-prevalence surveys showed an increase in prescribing appropriateness from 21 of 45 (46.7%) preintervention (October 2016) to 30 of 39 (76.9%) during the study period (September 2017).
The integration of EMR with an ICU-AMS program allowed us to implement a new AMS service, which was associated with high clinician compliance with recommendations and improved antibiotic appropriateness. Our “5 Moments of Antimicrobial Prescribing” metric provides a framework for measuring AMS recommendation compliance.
This article explores Washington's annotated copy of the Constitution and the Acts of Congress (hereafter called the Acts of Congress to remain consist with the label Washington had placed on the front cover) to reveal new insights into his constitutional interpretation. Held in a private collection until 2012, this article is the first to examine Washington's notations in the Acts of Congress for their value as statements about political authority. Washington's comments in the margins of his volume suggest an evolving view of presidential power and constitutional limitations on the executive branch as early as January 1790. His margin notes on the Acts of Congress served as blueprint for his defense of presidential authority and the expansion of the executive branch in the 1790s. Finally, the annotated Acts of Congress inserts Washington's ideas about the presidency into the debate surrounding originalism by revealing how his analysis of the language evolved to meet the demands of governing, leading him to reject the delegates' intent for Article II, Section 2 of the Constitution.
Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions.
Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls.
All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases.
A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE.
We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance (P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions (P = .008). PPE use was not significantly different before versus after the intervention (P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently.
HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.
Ultrasound applications are widespread, and their utility in resource-limited environments are numerous. In disasters, the use of ultrasound can help reallocate resources by guiding decisions on management and transportation priorities. These interventions can occur on-scene, at triage collection points, during transport, and at the receiving medical facility. Literature related to this specific topic is limited. However, literature regarding prehospital use of ultrasound, ultrasound in combat situations, and some articles specific to disaster medicine allude to the potential growth of ultrasound utilization in disaster response.
To evaluate the utility of point-of-care ultrasound in a disaster response based on studies involving ultrasonography in resource-limited environments.
A narrative review of MEDLINE, MEDLINE InProcess, EPub, and Embase found 20 articles for inclusion.
Experiences from past disasters, prehospital care, and combat experiences have demonstrated the value of ultrasound both as a diagnostic and interventional modality.
Current literature supports the use of ultrasound in disaster response as a real-time, portable, safe, reliable, repeatable, easy-to-use, and accurate tool. While both false positives and false negatives were reported in prehospital studies, these values correlate to accepted false positive and negative rates of standard in-hospital point-of-care ultrasound exams. Studies involving austere environments demonstrate the ability to apply ultrasound in extreme conditions and to obtain high-quality images with only modest training and real-time remote guidance. The potential for point-of-care ultrasound in triage and management of mass casualty incidents is there. However, as these studies are heterogeneous and observational in nature, further research is needed as to how to integrate ultrasound into the response and recovery phases.
General practices play an important role in the detection and treatment of depressive symptoms in older adults. An adapted version of the indicated preventive life review therapy group intervention called Looking for Meaning (LFM) was developed for general practice and a pilot evaluation was conducted.
A pretest-posttest design was used. One week before and one week after the intervention participants filled out questionnaires.
In six general practices in the Netherlands the adapted intervention was given.
Inclusion criteria were > 60 years and a score of 5 or higher on the Center for Epidemiological Studies Depression Scale (CES-D).
The length and number of LFM sessions were shortened and the intervention was given by one mental health care nurse practitioner (MHCNP).
The impact on mental health was analyzed by depressive symptoms (CES-D) as the primary outcome and anxiety symptoms (HADS-A), psychological well-being (PGCMS) and mastery (PMS) as secondary outcomes. An evaluative questionnaire was included to evaluate the feasibility and acceptability.
Most participants were satisfied with the adaptations of the number (72%) and length (72%) of sessions. The overall sample showed a significant decrease in depressive symptoms after the intervention. No impact was found on psychological well-being, anxiety symptoms and mastery.
The intervention is feasible and acceptable for older adults with depressive symptoms and has an impact on their depressive symptoms.
OBJECTIVES/SPECIFIC AIMS: Our primary objectives were to examine the impact of biologic cost sharing on 1) adherence to biologics and 2) persistence on biologics in inflammatory bowel disease (IBD) patients. Our secondary objective was to assess the effect of biologic cost sharing on clinical IBD outcomes, including rates of hospitalization, abdominal surgery, and corticosteroid treatment. METHODS/STUDY POPULATION: This retrospective cohort analysis used a national insurance claims database (Optum Clinformatics DataMart) to assess adult IBD patients enrolled in medium or large private insurance plans from 2007-2016. Patients were followed for one year of continuous enrollment after their index biologic claim. We assessed adherence to biologic medications (medication possession ratio >0.8) dependent on patient cost sharing, as measured by an employer-plan’s average out-of-pocket biologic medication cost. We also examined the effects of patient cost sharing for biologics on need for hospitalization, abdominal surgery, or corticosteroid treatment. We used multivariate logistic regression models adjusting for clinical and demographic characteristics. We estimated the effect of cost sharing on biologic therapy persistence using repeated measures proportional hazard survival models. RESULTS/ANTICIPATED RESULTS: We identified 2,193 adult IBD patients who initiated biologic therapy and met study criteria (Crohn’s disease 66.1% vs. ulcerative colitis 24.9%, mean age 40.8 years, mean Charlson index 0.50). Median [IQR] out-of-pocket cost per 30-day biologic prescription was $62 [$34 - $157]. 66.9% of patients were adherent to biologic therapy. Higher out-of-pocket costs for biologics were associated with increased odds of nonadherence; patients with ulcerative colitis were more price-responsive than patients with Crohn’s disease or indeterminate colitis (Figure 1). However, higher out-of-pocket biologic costs were not associated with increased odds of all-cause or IBD-related hospitalization, IBD-related surgery, or corticosteroid prescriptions for IBD flares. Patients whose out-of-pocket costs were less than $10 per 30-day biologic prescription persisted on biologic therapy for significantly longer than patients who paid >$10 (Figure 2). DISCUSSION/SIGNIFICANCE OF IMPACT: Nonadherence to biologics increases when IBD patients face higher out-of-pocket costs, particularly for ulcerative colitis patients. However, this is not associated with worse clinical outcomes. Patients with cost-sharing<$10 persisted on biologics longer than patients whose cost sharing exceeded $10.
Objectives: Prior research has identified numerous genetic (including sex), education, health, and lifestyle factors that predict cognitive decline. Traditional model selection approaches (e.g., backward or stepwise selection) attempt to find one model that best fits the observed data, risking interpretations that only the selected predictors are important. In reality, several predictor combinations may fit similarly well but result in different conclusions (e.g., about size and significance of parameter estimates). In this study, we describe an alternative method, Information-Theoretic (IT) model averaging, and apply it to characterize a set of complex interactions in a longitudinal study on cognitive decline. Methods: Here, we used longitudinal cognitive data from 1256 late–middle aged adults from the Wisconsin Registry for Alzheimer’s Prevention study to examine the effects of sex, apolipoprotein E (APOE) ɛ4 allele (non-modifiable factors), and literacy achievement (modifiable) on cognitive decline. For each outcome, we applied IT model averaging to a set of models with different combinations of interactions among sex, APOE, literacy, and age. Results: For a list-learning test, model-averaged results showed better performance for women versus men, with faster decline among men; increased literacy was associated with better performance, particularly among men. APOE had less of an association with cognitive performance in this age range (∼40–70 years). Conclusions: These results illustrate the utility of the IT approach and point to literacy as a potential modifier of cognitive decline. Whether the protective effect of literacy is due to educational attainment or intrinsic verbal intellectual ability is the topic of ongoing work. (JINS, 2019, 25, 119–133)
Inappropriate antibiotic use is associated with increased antimicrobial resistance and adverse events that can lead to further downstream patient harm. Preventative strategies must be employed to improve antibiotic use while reducing avoidable harm. We use the term “antibiotic never events” to globally recognize and define the most inappropriate antibiotic use.
Contemporary ice stream flow is directly linked to conditions at the ice/bed interface, yet this environment is logistically difficult to access. Instead, we investigate subglacial processes important for ice stream flow by studying tills on the deglaciated Antarctic continental shelf. We test currently-accepted hypotheses surrounding subglacial processes and till properties with a Ross Sea dataset. Till shear strengths indicate a continuum of simultaneous processes acting at the bed, rather than discrete ‘deformation’ and ‘lodgement’ end-members. We identify a threshold water content representing saturated pore spaces, leading to basal sliding and meltwater channelization. Based on observations of till properties relative to glacial landforms, we challenge the assumption that low shear strength is linked to intense deformation. Spatial variability in landform morphology reflects variability in deforming processes at the sub-ice stream scale and suggests a maximum deforming bed thickness of 2 m at the grounding line. Regional till properties generally correlate with seafloor geology and deglacial history; the western Ross Sea is characterized by higher and more variable shear strengths and water contents, while lower-shear strength till was preserved in the Eastern Basin. These observations inform till interpretation and provide context for deforming beds beneath the modern ice sheet and on glaciated continental shelves.
Objectives: A major challenge in cognitive aging is differentiating preclinical disease-related cognitive decline from changes associated with normal aging. Neuropsychological test authors typically publish single time-point norms, referred to here as unconditional reference values. However, detecting significant change requires longitudinal, or conditional reference values, created by modeling cognition as a function of prior performance. Our objectives were to create, depict, and examine preliminary validity of unconditional and conditional reference values for ages 40–75 years on neuropsychological tests. Method: We used quantile regression to create growth-curve–like models of performance on tests of memory and executive function using participants from the Wisconsin Registry for Alzheimer’s Prevention. Unconditional and conditional models accounted for age, sex, education, and verbal ability/literacy; conditional models also included past performance on and number of prior exposures to the test. Models were then used to estimate individuals’ unconditional and conditional percentile ranks for each test. We examined how low performance on each test (operationalized as <7th percentile) related to consensus-conference–determined cognitive statuses and subjective impairment. Results: Participants with low performance were more likely to receive an abnormal cognitive diagnosis at the current visit (but not later visits). Low performance was also linked to subjective and informant reports of worsening memory function. Conclusions: The percentile-based methods and single-test results described here show potential for detecting troublesome within-person cognitive change. Development of reference values for additional cognitive measures, investigation of alternative thresholds for abnormality (including multi-test criteria), and validation in samples with more clinical endpoints are needed. (JINS, 2019, 25, 1–14)