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Computable general equilibrium (CGE) models play an important role in supporting public-policy making on such issues as trade, climate change and taxation. This significantly revised volume, keeping pace with the next-generation standard CGE model, is the only undergraduate-level introduction of its kind. The volume utilizes a graphical approach to explain the economic theory underlying a CGE model, and provides results from simple, small-scale CGE models to illustrate the links between theory and model outcomes. Its eleven hands-on exercises introduce modelling techniques that are applied to real-world economic problems. Students learn how to integrate their separate fields of economic study into a comprehensive, general equilibrium perspective as they develop their skills as producers or consumers of CGE-based analysis.
Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents’ hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness.
Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5–7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis.
We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful.
Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.
To investigate the molecular epidemiology of methicillin-susceptible Staphylococcus aureus (MSSA) in infants in a neonatal intensive care unit (NICU) using whole-genome sequencing.
Investigation of MSSA epidemiology in a NICU.
Single-center, level IV NICU.
Universal S. aureus screening was done using a single swab obtained from the anterior nares, axilla, and groin area of infants in the NICU on a weekly basis. Core genome multilocus sequence type (cgMLST) analysis was performed on MSSA isolates detected over 1 year (2018–2019).
In total, 68 MSSA-colonized infants were identified, and cgMLSTs of 67 MSSA isolates were analyzed. Overall, we identified 11 cgMLST isolate groups comprising 39 isolates (58%), with group sizes ranging from 2 to 10 isolates, and 28 isolates (42%) were unrelated to each other or any of the isolate groups. Cases of infants colonized by MSSA were scattered throughout the 1-year study period, and isolates belonging to the same cgMLST group were typically detected contemporaneously, over a few weeks or a few months. Overall, 13 infants (19.7%) developed MSSA infections: bacteremia (n = 3), wound infection (n = 5), conjunctivitis (n = 4), and cellulitis (n = 1). We detected no association between these clinically manifest infections and specific cgMLST groups.
Although MSSA isolates in infants in a NICU showed high diversity, most were related to other isolates, albeit within small groups. cgMLST facilitates an understanding of the complex transmission dynamics of MSSA in NICUs, and these data can be used to inform better control strategies.
To evaluate the effectiveness of chlorhexidine (CHG) dressings to prevent catheter-related bloodstream infections (CRBSIs).
Systematic review and meta-analysis.
We searched PubMed, CINAHL, EMBASE, and ClinicalTrials.gov for studies (randomized controlled and quasi-experimental trials) with the following criteria: patients with short- or long-term catheters; CHG dressings were used in the intervention group and nonantimicrobial dressings in the control group; CRBSI was an outcome. Random-effects models were used to obtain pooled risk ratios (pRRs). Heterogeneity was evaluated using the I2 test and the Cochran Q statistic.
In total, 20 studies (18 randomized controlled trials; 15,590 catheters) without evidence of publication bias and mainly performed in intensive care units (ICUs) were included. CHG dressings significantly reduced CRBSIs (pRR, 0.71; 95% CI, 0.58–0.87), independent of the CHG dressing type used. Benefits were limited to adults with short-term central venous catheters (CVCs), including onco-hematological patients. For long-term CVCs, CHG dressings decreased exit-site/tunnel infections (pRR, 0.37; 95% CI, 0.22–0.64). Contact dermatitis was associated with CHG dressing use (pRR, 5.16; 95% CI, 2.09–12.70); especially in neonates and pediatric populations in whom severe reactions occurred. Also, 2 studies evaluated and did not find CHG-acquired resistance.
CHG dressings prevent CRBSIs in adults with short-term CVCs, including patients with an onco-hematological disease. CHG dressings might reduce exit-site and tunnel infections in long-term CVCs. In neonates and pediatric populations, proof of CHG dressing effectiveness is lacking and there is an increased risk of serious adverse events. Future studies should investigate CHG effectiveness in non-ICU settings and monitor for CHG resistance.
Postprandial glycaemia and insulinaemia are important risk factors for type 2 diabetes. The prevalence of insulin resistance in adolescents is increasing, but it is unknown how adolescent participant characteristics such as BMI, waist circumference, fitness and maturity offset may explain responses to a standard meal. The aim of the present study was to examine how such participant characteristics affect the postprandial glycaemic and insulinaemic responses to an ecologically valid mixed meal. Data from the control trials of three separate randomised, crossover experiments were pooled, resulting in a total of 108 participants (52 boys, 56 girls; age: 12.5±0.6 y; BMI: 19.05±2.66 kg·m-2). A fasting blood sample was taken for the calculation of fasting insulin resistance, using the HOMA-IR model. Further capillary blood samples were taken before and 30-, 60- and 120-min after a standardised lunch, providing 1.5 g.kg-1 body mass of carbohydrate, for the quantification of blood glucose and plasma insulin total area under the curve (tAUC). Hierarchical multiple linear regression demonstrated significant predictors for plasma insulin tAUC were waist circumference, physical fitness and HOMA-IR (F(3, 98)=36.78, p<.001, Adj. R2=.515). The variance in blood glucose tAUC was not significantly explained by the predictors used (F(7, 94)=1.44, p=.198). Significant predictors for HOMA-IR were BMI and maturity offset (F(2, 102)=14.06, p<.001, Adj. R2=.021). In summary, the key findings of the study are that waist circumference, followed by physical fitness, best explained the insulinemic response to an ecologically valid standardised meal in adolescents. This has important behavioural consequences because these variables can be modified.
Investigation of treatments that effectively treat adults with post-traumatic stress disorder from childhood experiences (Ch-PTSD) and are well tolerated by patients is needed to improve outcomes for this population.
The purpose of this study was to compare the effectiveness of two trauma-focused treatments, imagery rescripting (ImRs) and eye movement desensitisation and reprocessing (EMDR), for treating Ch-PTSD.
We conducted an international, multicentre, randomised clinical trial, recruiting adults with Ch-PTSD from childhood trauma before 16 years of age. Participants were randomised to treatment condition and assessed by blind raters at multiple time points. Participants received up to 12 90-min sessions of either ImRs or EMDR, biweekly.
A total of 155 participants were included in the final intent-to-treat analysis. Drop-out rates were low, at 7.7%. A generalised linear mixed model of repeated measures showed that observer-rated post-traumatic stress disorder (PTSD) symptoms significantly decreased for both ImRs (d = 1.72) and EMDR (d = 1.73) at the 8-week post-treatment assessment. Similar results were seen with secondary outcome measures and self-reported PTSD symptoms. There were no significant differences between the two treatments on any standardised measure at post-treatment and follow-up.
ImRs and EMDR treatments were found to be effective in treating PTSD symptoms arising from childhood trauma, and in reducing other symptoms such as depression, dissociation and trauma-related cognitions. The low drop-out rates suggest that the treatments were well tolerated by participants. The results from this study provide evidence for the use of trauma-focused treatments for Ch-PTSD.
Many studies have been devoted to the producers of Lutheran music in seventeenth-century Germany – composers, editors, publishers and printers. Little attention, however, has been paid to the tastes and preferences of the consumers of this music. This article represents the first study of this subject, and draws on music inventories and account books to examine the Lutheran market for sacred music during this period. It presents a number of key findings, all of which relate to purchasing patterns: that community members donated a considerable amount of music to Lutheran institutions; that music prices remained quite stable for decades; that Lutherans cultivated the older motet alongside the newer sacred concerto throughout much of the century; that Lutherans sought out music by Italians and northern Catholics as well as by Lutherans; and that after c. 1640, the composer Andreas Hammerschmidt dominated the Lutheran market for sacred music, outselling all of his contemporaries.
Temperament is linked to the structure and function of the nervous system and to the experience of the organism. When we measure the person’s readiness to anger, to seek reward, to focus and switch attention, etc., we are measuring temperament and these in turn are linked to brain networks. Hyperreactivity to an unexpected, novel or intense stimulus, is also a measure of temperament important in understanding the development of behavior problems in children and psychopathologies of stress and attention in adults (Rothbart, 2011; Zentner & Shiner, 2012). Studies of resting state MRI have allowed tracing humans brain changes from birth (Gao et al., 2016), allowing examination of the development of attention and other networks early in life. The advance of epigenetic studies (Meaney, 2010) has offered a framework for thinking about the how the environment and gene expression work in concert to produce the pattern of connectivity unique to the individual.
To explore, from the perspectives of adolescents and caregivers, and using qualitative methods, influences on adolescent diet and physical activity in rural Gambia.
Six focus group discussions (FGD) with adolescents and caregivers were conducted. Thematic analysis was employed across the data set.
Rural region of The Gambia, West Africa.
Participants were selected using purposive sampling. Four FGD, conducted with forty adolescents, comprised: girls aged 10–12 years; boys aged 10–12 years; girls aged 15–17 years, boys aged 15–17 years. Twenty caregivers also participated in two FGD (mothers and fathers).
All participants expressed an understanding of the association between salt and hypertension, sugary foods and diabetes, and dental health. Adolescents and caregivers suggested that adolescent nutrition and health were shaped by economic, social and cultural factors and the local environment. Adolescent diet was thought to be influenced by: affordability, seasonality and the receipt of remittances; gender norms, including differences in opportunities afforded to girls, and mother-led decision-making; cultural ceremonies and school holidays. Adolescent physical activity included walking or cycling to school, playing football and farming. Participants felt adolescent engagement in physical activity was influenced by gender, seasonality, cultural ceremonies and, to some extent, the availability of digital media.
These novel insights into local understanding should be considered when formulating future interventions. Interventions need to address these interrelated factors, including misconceptions regarding diet and physical activity that may be harmful to health.
Over the ages, clinicians have tried to decipher the mysteries of the human body by exploiting natural openings to examine the internal aspects of organs. Since as far back as Hippocrates, a variety of instruments have been employed to achieve this. The simplest form of instrument is a speculum, used to augment natural openings and allow ambient light to illuminate the inner aspect of organs for inspection by the naked eye. While this may be helpful for examining the nostrils or the vagina, for example, it is not an adequate approach for a well-concealed organ such as the uterus. Accurate endoscopic examination of the endometrial cavity, i.e. hysteroscopy, requires the transmission of light into and out of a cavity. Since the endometrial cavity is a potential space, collapsed in the natural state, a distension medium is required to expand the field of vision.
Endometrial ablation (EA) is a minimally invasive surgical intervention that aims to reduce heavy menstrual bleeding (HMB) by destroying functionally active endometrial glands within the endometrium and the superficial myometrium, including the deep basal glands. To prevent regeneration and stop menstruation this destruction should be to a depth of 5 mm. In the past, destruction of the endometrium required an operating hysteroscope. Endometrial tissue was either removed using an electrical cutting loop or destroyed by applying thermal energy to induce necrosis using an electrical ‘rollerball’ or laser fibre. These first-generation techniques have largely been superseded by second-generation techniques that comprise semi-automated global ablative systems using a variety of energy sources to thermally ablate the endometrium. These systems require less operator skill, are less likely to require general anaesthesia, are quicker to perform and offer enhanced safety with no loss in effectiveness.
The first part of this chapter has been written with the patient’s journey in mind: from the time of presentation to the general practitioner (GP) with a problem such as abnormal uterine bleeding, through referral to secondary care for investigation, including hysteroscopy if appropriate, and to treatment as indicated. We hope this approach will clarify what is involved in providing such a service. In the second half of the chapter, the equipment required for providing hysteroscopy services is described in detail, making extensive use of published standards and guidelines for gynaecology and hysteroscopy specifically.
Hysteroscopy involves both diagnostic and therapeutic procedures. Inpatient hysteroscopy is well established, but the development of outpatient services is relatively new. Audit is the process by which we assess a service against recognised standards; data collection enables us to perform an audit; clinical governance provides the framework for safe and effective patient care.
Surgical procedures using electrosurgery can be undertaken within the uterine cavity to address excessive menstrual blood loss and to enhance fertility. The insertion of specialised electrodes down hysteroscopic instruments enables the direct application of electricity to uterine tissue. The electrical energy is transformed into heat and, depending upon how this heat is focused, can be used to cut tissue and excise lesions, or cauterise and ablate tissue (Box 8.1). The larger hysteroscopic resectoscopes with outer diameters of 7 to 8.5 mm are generally, though not exclusively, used during inpatient procedures with a general anaesthetic or regional anaesthesia. The introduction of smaller electrodes (1.67 mm, or 5 Fr) has enabled therapeutic procedures to be undertaken using diagnostic hysteroscopes with an operating channel. This has supported the development of outpatient operative hysteroscopy for the removal of small intrauterine lesions.
Training allows healthcare professionals to develop skills that benefit patients, improve their care and keep them safe. It is an essential aspect of reducing or preventing harm to our patients.
Over the past two decades there has been a significant shift in surgical education away from an apprenticeship model that had existed for centuries towards the use of clinical skills and simulation training. This can be undertaken in a safe environment, allowing healthcare professionals to begin their learning and practice of skills away from patients. Proponents of the ‘new’ system point to the increased availability of simulation equipment, both low (sometimes called basic) and high fidelity (virtual reality high technology systems), in NHS hospitals and university departments throughout the UK. In addition, there is a wealth of evidence supporting simulation as an important educational tool in medicine that has the potential to significantly reduce the chances of harm to patients.
Improved hysteroscopic technology has enabled clinicians not only to perform diagnostic outpatient hysteroscopy but also to treat uterine lesions. Bipolar diathermy electrodes have reduced the risk of fluid overload, allowing the excision of larger fibroids at a single setting and thus reducing the need for abdominal operations. Novel indications for hysteroscopy have become available, such as hysteroscopic tubal occlusion. Concomitant developments in hysteroscopic equipment and ultrasound technology have influenced how these tools are used in the diagnosis and treatment of intrauterine conditions.
The uterus is the primary female reproductive organ. It is situated within the pelvis and measures approximately 8 cm in length, 4 cm in width and 5 cm in depth in the normal, non-pregnant state. Though relatively quiescent in pre-pubertal and post-menopausal years, the uterus possesses a variety of functions during a woman’s reproductive years. It responds to the production of female hormones, creating changes to allow for implantation of a fertilised egg, or menstruation when pregnancy does not occur. It is also able to rapidly expand with the development of a pregnancy and has a contractile function for labour and delivery during childbirth .