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Many Western countries have seen an increase in the volume and importance of external consultants in the public policy process. This book is the first to investigate this phenomenon in a comparative and interdisciplinary way. The analysis shows who these consultants are, how widely and for what reasons they are used in Britain, the United States, Canada, Australia, The Netherlands and Sweden. In doing so, the book addresses the positive and negative implications of high levels of external policy consultancy, including its implications for the nature of the state (transforming into a contractor state?) and for democratically legitimized and accountable decision-making (transforming into consultocracy?). It provides valuable new insights for students and practitioners in the fields of public administration, public policy, public management, political science and human resource management.
The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams.
The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here.
The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020.
Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.
After five positive randomized controlled trials showed benefit of mechanical thrombectomy in the management of acute ischemic stroke with emergent large-vessel occlusion, a multi-society meeting was organized during the 17th Congress of the World Federation of Interventional and Therapeutic Neuroradiology in October 2017 in Budapest, Hungary. This multi-society meeting was dedicated to establish standards of practice in acute ischemic stroke intervention aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing medical thrombectomy for acute ischemic stroke, but not for other neurovascular diseases (level 2 centers). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (level 3 centers). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The multi-society group provides recommendations and a framework for the development of medical thrombectomy services worldwide.
Osagie K. Obasogie's Blinded by Sight: Seeing Race through the Eyes of the Blind (2014) makes important contributions to both to the sociology of law and to critical race studies. The book challenges “colorblind” racial ideology by showing empirically that people who are blind from birth nevertheless “see” race, grasping it as a nearly omnipresent feature of social interaction and social organization. These insights, however, do not diminish the importance of the racial body. Beyond refuting colorblindness, Obasogie's book points to a neverending tension, embedded in what we call racial formation, between the social construction of race and the corporeality of race. This tension has been present since the dawn of empire and African slavery. Obasogie's achievement of falsifying colorblindness should not lead us to neglect the importance of the racial body.
To identify potential participants for clinical trials, electronic health records (EHRs) are searched at potential sites. As an alternative, we investigated using medical devices used for real-time diagnostic decisions for trial enrollment.
To project cohorts for a trial in acute coronary syndromes (ACS), we used electrocardiograph-based algorithms that identify ACS or ST elevation myocardial infarction (STEMI) that prompt clinicians to offer patients trial enrollment. We searched six hospitals’ electrocardiograph systems for electrocardiograms (ECGs) meeting the planned trial’s enrollment criterion: ECGs with STEMI or > 75% probability of ACS by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI). We revised the ACI-TIPI regression to require only data directly from the electrocardiograph, the e-ACI-TIPI using the same data used for the original ACI-TIPI (development set n = 3,453; test set n = 2,315). We also tested both on data from emergency department electrocardiographs from across the US (n = 8,556). We then used ACI-TIPI and e-ACI-TIPI to identify potential cohorts for the ACS trial and compared performance to cohorts from EHR data at the hospitals.
Receiver-operating characteristic (ROC) curve areas on the test set were excellent, 0.89 for ACI-TIPI and 0.84 for the e-ACI-TIPI, as was calibration. On the national electrocardiographic database, ROC areas were 0.78 and 0.69, respectively, and with very good calibration. When tested for detection of patients with > 75% ACS probability, both electrocardiograph-based methods identified eligible patients well, and better than did EHRs.
Using data from medical devices such as electrocardiographs may provide accurate projections of available cohorts for clinical trials.
A synthesis method to form foams consisting of a shell of metals conformally coated on carbon nanotube (CNT) arrays by electroplating from a single bath electrolyte is demonstrated in this work. A triple cyclic pulse electrodeposition technique was used to deposit Ni and Cu layers on the CNT arrays, and electron microscopy was then used to identify conditions amenable to semi-conformal and island growth morphologies. Nanoindentation of the resulting metallic-CNT composite foam structure, using a flat punch/compression geometry, demonstrates that adding metallic shells to the CNT turf to create a metallic low density foam increases both the hardness and elastic modulus; however, once island growth initiates there is no significant subsequent increase in mechanical properties with increases in deposited metals.
The rate of cardiovascular implantable electronic device (CIED) infection is increasing coincident with an increase in the number of device procedures. Preprocedural antimicrobial prophylaxis reduces CIED infections; however, there is no evidence that prolonged postprocedural antimicrobials additionally reduce risk. Thus, we sought to quantify the harms associated with this approach.
To measure the association between Clostridium difficile infection (CDI), acute kidney injury (AKI) and receipt of prolonged postprocedural antimicrobials.
CIED procedures entered into the VA Clinical Assessment Reporting and Tracking Electrophysiology (CART-EP) database during fiscal years 2008–2016 were included. The primary outcome was 90-day incidence of CDI and the secondary outcome was the 7-day incidence of AKI. The primary exposure measure was duration of postprocedural antimicrobial therapy. Associations were measured using Cox-proportional hazards and binomial regression.
Prolonged postprocedural antimicrobial therapy was identified following 3,331 of 6,497 CIED procedures (51.3%), and the median duration of prophylaxis was 5 days. Prolonged postprocedural antimicrobial use was associated with increased risk of CDI (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.54–5.46). Of the 27 patients who developed CDI, 11 subsequently died. Postprocedural antimicrobial use with ≥2 antimicrobials was associated with an increased risk of AKI (OR, 4.16; 95% CI, 2.50–6.90). The impact was particularly significant when one of the dual agents prescribed was vancomycin (adjusted OR, 8.41; 95% CI, 5.53–12.79).
Prolonged antimicrobial prophylaxis following CIED procedures increases preventable harm; this practice should be discouraged in procedural settings such as the cardiac electrophysiology laboratory.
A synthesis method to form conformal core-shell foams of metals and alloys on a carbon nanotube (CNT) scaffold by electroplating from a single bath electrolyte is demonstrated in this work. A triple cyclic pulse electrodeposition technique was used to deposit Ni and Cu layers on the CNT scaffold, and electron microscopy was then used to identify conditions amenable to conformal and island growth morphologies. Nanoindentation of the resulting metallic foam structure, using a flat punch/compression geometry, demonstrates that adding conformal metallic shells to the CNT turf to create a metal coated low density foam increases both the hardness and elastic modulus; however, once island growth initiates there is no significant subsequent increase in mechanical properties with increases in deposited metals.
Background: Central neuropathic pain syndromes are a result of central nervous system injury, most commonly related to stroke, traumatic spinal cord injury, or multiple sclerosis. These syndromes are distinctly less common than peripheral neuropathic pain, and less is known regarding the underlying pathophysiology, appropriate pharmacotherapy, and long-term outcomes. The objective of this study was to determine the long-term clinical effectiveness of the management of central neuropathic pain relative to peripheral neuropathic pain at tertiary pain centers. Methods: Patients diagnosed with central (n=79) and peripheral (n=710) neuropathic pain were identified for analysis from a prospective observational cohort study of patients with chronic neuropathic pain recruited from seven Canadian tertiary pain centers. Data regarding patient characteristics, analgesic use, and patient-reported outcomes were collected at baseline and 12-month follow-up. The primary outcome measure was the composite of a reduction in average pain intensity and pain interference. Secondary outcome measures included assessments of function, mood, quality of life, catastrophizing, and patient satisfaction. Results: At 12-month follow-up, 13.5% (95% confidence interval [CI], 5.6-25.8) of patients with central neuropathic pain and complete data sets (n=52) achieved a ≥30% reduction in pain, whereas 38.5% (95% CI, 25.3-53.0) achieved a reduction of at least 1 point on the Pain Interference Scale. The proportion of patients with central neuropathic pain achieving both these measures, and thus the primary outcome, was 9.6% (95% CI, 3.2-21.0). Patients with peripheral neuropathic pain and complete data sets (n=463) were more likely to achieve this primary outcome at 12 months (25.3% of patients; 95% CI, 21.4-29.5) (p=0.012). Conclusion: Patients with central neuropathic pain syndromes managed in tertiary care centers were less likely to achieve a meaningful improvement in pain and function compared with patients with peripheral neuropathic pain at 12-month follow-up.
Improving geolocation accuracy in text data has long been a goal of automated text processing. We depart from the conventional method and introduce a two-stage supervised machine-learning algorithm that evaluates each location mention to be either correct or incorrect. We extract contextual information from texts, i.e., N-gram patterns for location words, mention frequency, and the context of sentences containing location words. We then estimate model parameters using a training data set and use this model to predict whether a location word in the test data set accurately represents the location of an event. We demonstrate these steps by constructing customized geolocation event data at the subnational level using news articles collected from around the world. The results show that the proposed algorithm outperforms existing geocoders even in a case added post hoc to test the generality of the developed algorithm.
Survivors of adolescent and young adult (AYA) central nervous system (CNS) neoplasms are at risk for late effects (LE) - treatment-related health problems occurring more than 5 years after therapy). Since, in Canada, AYA survivors are usually followed in the community, information must be conveyed to primary care providers to guide risk-based follow-up care. Objective: To assess documentation of LE risks and screening recommendations (SR) in medical records of AYA CNS tumor survivors treated with radiation therapy. Methods: The medical records of all patients diagnosed with a CNS neoplasm (benign or malignant) at ages 15-39 years, treated between 1985 and 2010 in the province of British Columbia, surviving >5 years and discharged to the community were assessed. Documentation of LE and SR were extracted, and analyzed descriptively. Results: Among 132 survivors (52% female), treated with radiation therapy (95% partial brain, 10% craniospinal, 8% partial spine, and 4% whole brain) and chemotherapy (17%), 19% of charts included no documentation of LE risks, 26% included only non-specific documentation, and 55% had minimal documentation (1 or 2 LE). Documentation of at least one specific LE increased from 24% in 1980-1989, to 54% in 1990-1999, to 86% in 2000 – 2010. Based on treatment information, all survivors were at high-risk for LE, such as radiation induced neoplasm, meningioma and cerebrovascular events. Yet, SR were documented in only 25% of charts. Conclusions: The documentation of LE risks and screening recommendations has been limited, highlighting the need to improve written communication with primary care providers.
Consider the dynamics of a healing film driven by surface tension, that is, the inward spreading process of a liquid film to fill a hole. The film is modelled using the lubrication (or thin-film) approximation, which results in a fourth-order nonlinear partial differential equation. We obtain a self-similar solution describing the early-time relaxation of an initial step-function condition and a family of self-similar solutions governing the finite-time healing. The similarity exponent of this family of solutions is not determined purely from scaling arguments; instead, the scaling exponent is a function of the finite thickness of the prewetting film, which we determine numerically. Thus, the solutions that govern the finite-time healing are self-similar solutions of the second kind. Laboratory experiments and time-dependent computations of the partial differential equation are also performed. We compare the self-similar profiles and exponents, obtained by matching the estimated prewetting film thickness, with both measurements in experiments and time-dependent computations near the healing time, and we observe good agreement in each case.
Patient-reported outcome measures (PROMs) provide a way to measure the impact of a disease and its associated treatments on the quality of life from the patients’ perspective. The aim of this review was to identify PROMs that have been developed and/or validated in patients with carotid artery disease (CAD) undergoing revascularization, and to assess their psychometric properties and examine suitability for research and clinical use.
Eight electronic databases including MEDLINE and CINAHL were searched from inception to May 2015 and updated in the MEDLINE database to February 2017. A two-stage search approach was used to identify studies reporting the development and/or validation of relevant PROMs in patients with CAD undergoing revascularization. Supplementary citation searching and hand-searching reference lists of included studies were also undertaken. The Consensus-based standards for the selection of health measurement instruments (COSMIN) and Oxford criteria were used to assess the methodological quality of the included studies, and the psychometric properties of the PROMs were evaluated using established assessment criteria.
Six PROMs, reported in five studies, were identified: 36-Item Short Form Health Survey (SF-36), Euro-QoL-5-Dimension Scale (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Dizziness Handicap Inventory (DHI), Quality of life for CAD scale by Ivanova 2015 and a disease-specific PROM designed by Stolker 2010. The rigour of the psychometric assessment of the PROMs were variable with most only attempting to assess a single psychometric criterion. No study reported evidence on criterion validity and test-retest reliability. The overall psychometric evaluation of all included PROMs was rated as poor.
This review highlighted a lack of evidence in validated PROMs used for patients undergoing carotid artery revascularization. As a result, the development and validation of a new PROM for this patient population is warranted in order to provide data which can supplement traditional clinical outcomes (stroke >30 days post-procedural, myocardial infarction and death), and capture changes in health status and quality of life in patients to help inform treatment decisions.
Little is known about the joint mental health effects of air pollution and tobacco smoking in low- and middle-income countries.
To investigate the effects of exposure to ambient fine particulate matter pollution (PM2.5) and smoking and their combined (interactive) effects on depression.
Multilevel logistic regression analysis of baseline data of a prospective cohort study (n=41785). The 3-year average concentrations of PM2.5 were estimated using US National Aeronautics and Space Administration satellite data, and depression was diagnosed using a standardised questionnaire. Three-level logistic regression models were applied to examine the associations with depression.
The odds ratio (OR) for depression was 1.09 (95% CI 1.01–1.17) per 10 μg/m3 increase in ambient PM2.5, and the association remained after adjusting for potential confounding factors (adjusted OR = 1.10, 95% CI 1.02–1.19). Tobacco smoking (smoking status, frequency, duration and amount) was also significantly associated with depression. There appeared to be a synergistic interaction between ambient PM2.5 and smoking on depression in the additive model, but the interaction was not statistically significant in the multiplicative model.
Our study suggests that exposure to ambient PM2.5 may increase the risk of depression, and smoking may enhance this effect.
Close-binary planetary-nebula nuclei (PNNs) provide direct evidence for occurrence of a common-envelope phase in binary-star evolution. Their descendants are V471 Tauri-type detached binaries, cataclysmic binaries, and possibly Type I supernovae. Thirteen close-binary PNNs are now known from periodic photometric or radial-velocity variations, or from composite optical/UV spectra. At least 10% of PNNs are close binaries, a fraction more than sufficient to account for the formation of all of the cataclysmic variables in the solar neighborhood. The Abell 35-type binary PNNs, a class with three known members, contain rapidly rotating, chromospherically active late-type primary stars along with extremely hot companions detected with the IUE satellite.
This paper deals with the central stars of two large, low-surface-brightness planetary nebulae: V605 Aquilae, central star of Abell 58, and 0950+139, central star of EGB 6. Both of these nuclei are associated with compact emission-line nebulosities, which are unresolved from the ground. We obtained images with the Faint Object Camera (FOC) on the Hubble Space Telescope of both objects, in order to determine the nature of the compact nebulae.
The nuclei of the low-surface-brightness PNe A 35, LoTr 1, and LoTr 5 are binaries containing rapidly rotating late-type subgiants or giants and extremely hot (Teff ≳ 100,000 K) companions detected by the IUE satellite. All three objects show low-amplitude, periodic photometric variations in the optical band (with periods of 0.76 or 3.3, 6.6, and 5.9 days, respectively).
Self consistent neutron star atmospheric models have been constructed which include the effects of Comptonization, free-free and bound-free absorption. It has been demonstrated that for parameters relevant to x-ray bursting neutron stars the atmosphere does not radiate like a blackbody during any phase of an x-ray burst. In particular, during the initial rise and final decline of the burst the temperature structure of the atmosphere is affected by backwarming associated with the high opacity due to free-free processes at low frequencies to an extent that the radiation spectrum is shifted to higher energies than a blackbody of the same effective temperature. On the other hand, near the peak of the burst, the opacity is more gray-like as the electron scattering opacity dominates; however, in this case thermalizaton of the radiation field occurs at such large optical depths (τ ∼ 5) that the spectral temperature is higher than the effective temperature. This result is found despite the importance of Comptonization in the thermalization process. Thus, the super Eddington fluxes implied by the spectral data alone are misleading and result from the improper use of the spectral temperature for the effective temperature. For neutron stars characterized by a soft equation of state and radiating near the Eddington effective temperature, fluxes obtained in this way could be overestimated by a factor of about 5.
We used measurements of radar-detected stratigraphy, surface ice-flow velocities and accumulation rates to investigate relationships between local valley-glacier and regional ice-sheet dynamics in and around the Schmidt Hills, Pensacola Mountains, Antarctica. Ground-penetrating radar profiles were collected perpendicular to the long axis of the Schmidt Hills and the margin of Foundation Ice Stream (FIS). Within the valley confines, the glacier consists of blue ice, and profiles show internal stratigraphy dipping steeply toward the nunataks and truncated at the present-day ablation surface. Below the valley confines, the blue ice is overlain by firn. Data show that upward-progressing overlap of actively accumulating firn onto valley-glacier ice is slightly less than ice flow out of the valleys over the past ∼1200 years. The apparent slightly negative mass balance (-0.25 cm a-1) suggests that ice-margin elevations in the Schmidt Hills may have lowered over this time period, even without a change in the surface elevation of FIS. Results suggest that (1) mass-balance gradients between local valley glaciers and regional ice sheets should be considered when using local information to estimate regional ice surface elevation changes; and (2) interpretation of shallow ice structures imaged with radar can provide information about local ice elevation changes and stability.