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The cost-effectiveness of endovascular therapy (EVT) compared to tissue plasminogen activator (tPA) alone for acute ischemic stroke (AIS) has been established in the literature. However, decision-makers still face challenges of how to best deliver EVT in a timely manner to maximize patient outcomes while minimizing the burden to the healthcare system, given that AIS has time-dependent treatment outcomes. The objective of this presentation is to report an optimization approach for improving health system value and outcomes for patients with AIS who are eligible for EVT in Alberta.
An economic model was developed to compare combinations of “mothership” (transport directly to a comprehensive stroke center [CSC] to receive tPA and EVT) and “drip-and-ship” (transport to a primary stroke centre to receive tPA, followed by transport to a CSC to receive EVT) methods across Alberta. The model considered geographical variation and searched for the best delivery methods through a pairwise comparison of all possible strategies. The controlled variables including in the model were population densities, disease epidemiology, time/distance to hospitals, available medical services, treatment eligibility and efficacy, and costs. Patient outcomes were measured by functional independence. The model defined optimal strategies by identifying the transport methods that produced the highest probability of improved health outcomes at the lowest cost.
The analysis produced an optimization map showing optimal strategies for EVT delivery. The lifetime cost (standard deviation [SD]) per patient and likelihood (SD) of good outcomes was CAD 291,769 (CAD 11,576) [USD 226,207 (USD 8,975)] and 41.82 percent (0.013) when considering optimal clinical outcomes, and CAD 287,725 (CAD 4,141) [USD 223,097 (USD 3,211)] and 41.67 percent (0.016) when considering optimal economic efficiency.
Our model reduces the gap that exists between health technology implementation and cost-effectiveness analysis; namely, neither fully addresses relative efficiency driven by geographical variation, which may misrepresent system value in local settings. Implementation strategies generated in our model capture full values in terms of patient outcomes and costs.
Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals.
Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017.
A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60–103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22–42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period.
Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.
Good education requires student experiences that deliver lessons about practice as well as theory and that encourage students to work for the public good—especially in the operation of democratic institutions (Dewey 1923; Dewy 1938). We report on an evaluation of the pedagogical value of a research project involving 23 colleges and universities across the country. Faculty trained and supervised students who observed polling places in the 2016 General Election. Our findings indicate that this was a valuable learning experience in both the short and long terms. Students found their experiences to be valuable and reported learning generally and specifically related to course material. Postelection, they also felt more knowledgeable about election science topics, voting behavior, and research methods. Students reported interest in participating in similar research in the future, would recommend other students to do so, and expressed interest in more learning and research about the topics central to their experience. Our results suggest that participants appreciated the importance of elections and their study. Collectively, the participating students are engaged and efficacious—essential qualities of citizens in a democracy.
The objective of this study was to examine the association between dietary inflammatory potential and memory and cognitive functioning among a representative sample of the US older adult population. Cross-sectional data from the 2011–2012 and 2013–2014 National Health and Nutrition Examination Survey were utilised to identify an aggregate sample of adults 60–85 years of age (n 1723). Dietary inflammatory index (DII®) scores were calculated using 24-h dietary recall interviews. Three memory-related assessments were employed, including the Consortium to Establish a Registry for Alzheimer’s disease (CERAD) Word Learning subset, the Animal Fluency test and the Digit Symbol Substitution Test (DSST). Inverse associations were observed between DII scores and the different memory parameters. Episodic memory (CERAD) (badjusted=−0·39; 95 % CI −0·79, 0·00), semantic-based memory (Animal Fluency Test) (badjusted=−1·18; 95 % CI −2·17, −0·20) and executive function and working-memory (DSST) (badjusted=−2·80; 95 % CI −5·58, −0·02) performances were lowest among those with the highest mean DII score. Though inverse relationships were observed between DII scores and memory and cognitive functioning, future work is needed to further explore the neurobiological mechanisms underlying the complex relationship between inflammation-related dietary behaviour and memory and cognition.
This article outlines a new method for surveys to study elections and voter attitudes. Pre-election surveys often suffer from an inability to identify and survey the likely electorate for the upcoming election. We propose a new and inexpensive method to conduct representative surveys of the electorate. We demonstrate the performance of our method in producing a representative sample of the future electorate that can be used to study campaign dynamics and many other issues. We compare pre-election outcome forecasts to election outcomes in seven primary and general election surveys conducted prior to the 2008 and 2010 primary and general elections in three states. The results indicate that the methodology produces representative samples, including in low-turnout elections such as primaries where traditional methods have difficulty consistently sampling the electorate. This new methodology combines Probability Proportional to Size (PPS) sampling, mailed invitation letters, and online administration of the questionnaire. The PPS sample is drawn based on a model employing variables from the publicly available voter file to produce a probability of voting score for each individual voter. The proposed method provides researchers a valuable tool to study the attitudes of the voting public.
Background: Stroke patients of lower socioeconomic status have worse outcomes. It remains poorly understood whether this is due to illness severity or personal or health system barriers. We explored the experiences of stroke patients with financial barriers in a qualitative descriptive pilot study, seeking to capture perceived challenges that interfere with their poststroke health and recovery. Methods: We interviewed six adults with a history of stroke and financial barriers in Alberta, Canada, inquiring about their: (1) experiences after stroke; (2) experience of financial barriers; (3) perceived reasons for financial barriers; (4) health consequences of financial barriers; and (5) mechanisms for coping with financial barriers. Two reviewers analyzed data using inductive thematic analysis. Results: The participants developed new or worsened financial circumstances as a consequence of stroke-related disability. Poststroke impairments and financial barriers took a toll on their mental health. They struggled to access several aspects of long-term poststroke care, including allied health professional services, medications, and proper nutrition. They described opportunity costs and tradeoffs when accessing health services. In several cases, they were unaware of health resources available to them and were hesitant to disclose their struggles to their physicians and even their families. Conclusion: Some patients with financial barriers perceive challenges to accessing various aspects of poststroke care. They may have inadequate knowledge of resources available to them and may not disclose their concerns to their health care team. This suggests that providers themselves might consider asking stroke patients about financial barriers to optimize their long-term poststroke care.
We describe progress in developing a novel miniaturized laser-heated “microfurnace” aimed at preparing ultra-small (∼5 μg) graphite samples from CO2 (Smith et al. 2006, 2007, 2010). Recent effort has focused on automation of the process using a LabVIEW interface, which has permitted feedback control of the catalyst temperature as the reaction proceeds and the logging of reaction parameters. We trialed a number of different pure iron catalysts as well as Fe2O3 (which is reduced in situ to iron) and discuss the reaction rates. We studied the graphite morphology by scanning electron microscopy (SEM) and found there is a marked difference in graphite morphology with catalyst type. We assessed how each catalyst performs in the cesium sputter ion source of the ANTARES Accelerator Mass Spectrometry (AMS) facility. We utilized a quadrupole mass spectrometer to study the gas composition during the reaction, in order to better understand the underlying chemical reactions for such small samples and to better estimate the overall efficiency of the process. Results show that all CO2 is converted to CO by reduction on the iron catalyst within a few minutes of applying laser power. The reaction pressure stabilizes after 40 min; however, some CO is not converted to graphite. The cold trap temperature of –80 ° is effective at trapping H2O, so there is little CH4 production.
The imposition of male sexual characteristics onto the female (imposex) is present in wild populations of the non-native veined rapa whelk (Rapana venosa) in Chesapeake Bay, USA but does not appear to compromise reproductive function. Cultured whelks were used to test two hypotheses: (1) Observed imposex metrics will be similar to tributyltin (TBT) water concentrations at each of three sites; (2) Male and imposex/female whelks from the same site will have similar TBT body burdens. Cultured 2-year-old whelks were transplanted to three field sites in the York River, USA at the onset of their second reproductive season. Transplant site mean TBT water concentrations ranged from 1.4 ± 0.77 to 64.2 ± 57.8 ng l−1. Imposex incidence was 100% after 28 weeks with an observed M:F:IF ratio of 81:0:92 across all sites. Imposex stages (median vas deferens scale index = 4) and reproductive output were similar across sites. The imposex severity (IS = penis length/shell length) increased with increasing TBT concentrations. The relative penis length (RPLI) and relative penis size (RPSI) indices were positively related to site-specific TBT levels. Male whelks accumulated significantly higher TBT concentrations than female whelks at the site with the highest TBT concentration. Mean TBT concentrations in whelk egg capsules were significantly higher than concentrations in male or female whelk tissue. Egg capsule deposition provides a depuration mechanism for female whelks to reduce body burden of lipophilic TBT. Sex, season and reproductive status should be considered when using gastropod bioaccumulation to monitor TBT effects.
I want to thank all the contributors to this book for having taken the time and trouble to critique my recent work. It is an honor that I have experienced before, and I love it.
The third and fourth volumes of The Sources of Social Power bring to an end my history of power relations in human societies. Volume 3 begins for the most advanced countries in 1918. Yet since my second volume on the long nineteenth century largely ignored the empires of that time, in Volume 3, I actually start my discussion of empires much further back. Volume 3 then takes the narrative forward to the end of the Second World War, and then Volume 4 takes over up to (almost) the present day. The amount of empirical material I read for these volumes is large but very far from exhaustive, since an enormous amount has been written about the modern period. It would be very surprising if I did not make mistakes or depended on unreliable historians or took one viewpoint in highly controversial debates.
But my narrative is not merely empirical. It is informed by sociological theory. As before, I structure my narrative in terms of the interplay of four power sources, each one of which generates its own networks of interaction. The four are ideological, economic, military and political power. Although all four are often entwined with each other, each has its own distinct logic of development, and so their relations with each other are ultimately “orthogonal,” independent and irreducible one to another. Thus, while in these periods I persistently stress the importance to social development of capitalism, I am also persistently critical of economic determinism, whether this comes from Marxism or neo-classical economics. Similarly, while recognizing the importance of ideologies in these periods, I reject the idealism which pervades much of the so-called cultural turn in sociology. For military power I try to correct the opposite tendency, the neglect until very recently of the importance of war and armed forces in social development. I would like to believe that the recent revival of interest in military power owes something to my influence. I will say something later in this essay about the continuing political importance of the nation-state.
The pre-world war I period decisively structured modern class relations in Europe and the United States. Farmers, the largest population group, greatly influenced the development of capitalism and states. Scholars have demonstrated farmers’ significance in particular areas (e.g., Blackbourn in Germany and Esping-Andersen in Scandinavia), but there has been little comparative analysis. Farmer politics, and thus modern class relations in general, have been inadequately theorized. Most existing work on agrarian classes has also been economistic, neglecting politics. We fill the gaps by analyzing agrarian politics in the United States, France, Denmark, Norway, Sweden, Germany, Austria-Hungary, and Russia.
We use the underlying data of the IMPLAN Pro 3.0 regional economic simulation model to estimate the current economic contribution of Michigan's local food system and explore the chain of transactions giving rise to consumption of locally sourced goods from producer to processor to consumption. The proposed methodology includes both unprocessed and processed foods in the estimation of the local food system's economic value. The model also provides a replicable and consistent approach to estimating the value of local food systems within regional and state economies.