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The consistent association between therapeutic alliance and outcome underlines the importance of identifying factors which predict the development of a positive alliance. However, only few studies have examined the association between pretreatment characteristics and alliance formation in patients with schizophrenia.
The study examined whether symptoms and insight would predict the therapeutic alliance in psychotherapy of schizophrenia. Further, the associations and differences between patient and therapist alliance ratings were studied.
Eighty patients with schizophrenia spectrum disorders received manual-based psychotherapy. Assessment of symptoms and insight was conducted at baseline, and questionnaire-based alliance ratings were obtained three weeks into treatment. Patient and therapist alliance ratings were examined separately.
Patient and therapist alliance ratings were not significantly correlated (r = 0.17). Patient ratings of the alliance were significantly higher than the ratings of their therapists (d = 0.73). More insight in psychosis significantly predicted higher patient ratings of the alliance. Less positive and negative symptoms were significant predictors of higher therapist alliance ratings.
The findings indicate that symptoms and insight have an influence on the therapeutic alliance in the treatment of schizophrenia spectrum disorders. Patients' and therapists' perceptions of the alliance do not seem to demonstrate much convergence.
To examine the impact of determinants of incident dementia in three different old age groups (75–79, 80–84, 85+years) in Germany.
Multicenter prospective AgeCoDe/AgeQualiDe cohort study with baseline and nine follow-up assessments at 1.5-year intervals.
Primary care medical record registry sample.
General practitioners’ (GPs) patients aged 75+years at baseline.
Conduction of standardized interviews including neuropsychological assessment and collection of GP information at each assessment wave. We used age-stratified competing risk regression models (accounting for the competing event of mortality) to assess determinants of incident dementia and age-stratified ordinary least square regressions to quantify the impact of identified determinants on the age at dementia onset.
Among 3027 dementia-free GP patients, n = 704 (23.3%) developed dementia during the 13-year study period. Worse cognitive performance and subjective memory decline with related worries at baseline, and the APOE ε4 allele were associated independently with increased dementia risk in all three old age groups. Worse cognitive performance at baseline was also associated with younger age at dementia onset in all three age groups. Other well-known determinants were associated with dementia risk and age at dementia onset only in some or in none of the three old age groups.
This study provides further evidence for the age-specific importance of determinants of incident dementia in old age. Such specifics have to be considered more strongly particularly with regard to potential approaches of early detection and prevention of dementia.
This paper develops a generalization about agreement in German copula constructions described in Coon et al. (2017), and proposes an analysis that ties it to other well-established hierarchy phenomena. Specifically, we show that “assumed-identity” copula constructions in German exibit both person and number hierarchy effects, and that these extend beyond the “non-canonical” or “inverse” agreement patterns described in previous work on copula constructions (e.g., Béjar and Kahnemuyipour 2017 and works cited there). We present experimental evidence to support this generalization, and then develop an account that unifies it with hierarchy phenomena in other languages, with a focus on PCC effects. Specifically, we propose that what German copula constructions have in common with PCC environments is that there are multiple accessible DPs in the domain of a single agreement probe, the lower of which is more featurally specified than the higher (see, e.g., Béjar and Rezac 2003, 2009; Anagnostopoulou 2005; Nevins 2007). We also offer an explanation as to why number effects are present in German copula constructions but notably absent in PCC effects. We then place our account within the broader context of constraints on predication structures.
Hand hygiene compliance rates were estimated using direct observations. An AHHMS, installed on 4 nursing units in a sequential manner, determined hand hygiene performance rates, expressed as the number of hand hygiene events performed upon entering and exiting patient rooms divided by the number of room entries and exits. Additional strategies implemented to improve hand hygiene included goal setting, hospital leadership support, feeding AHHMS data back to healthcare personnel, and use of Toyota Kata performance improvement methods. HAIs were defined using National Healthcare Safety Network criteria.
Hand hygiene compliance rates generated by direct observation were substantially higher than performance rates generated by the AHHMS. Installation of the AHHMS without supplementary activities did not yield sustained improvement in hand hygiene performance rates. Implementing several supplementary strategies resulted in a statistically significant 85% increase in hand hygiene performance rates (P < .0001). The incidence density of non–Clostridioies difficile HAIs decreased by 56% (P = .0841), while C. difficile infections increased by 60% (P = .0533) driven by 2 of the 4 study units.
Implementation of an AHHMS, when combined with several supplementary strategies as part of a multimodal program, resulted in significantly improved hand hygiene performance rates. Reductions in non–C. difficile HAIs occurred but were not statistically significant.
Increased neural error-signals have been observed in obsessive-compulsive disorder (OCD), anxiety disorders, and inconsistently in depression. Reduced neural error-signals have been observed in substance use disorders (SUD). Thus, alterations in error-monitoring are proposed as a transdiagnostic endophenotype. To strengthen this notion, data from unaffected individuals with a family history for the respective disorders are needed.
The error-related negativity (ERN) as a neural indicator of error-monitoring was measured during a flanker task from 117 OCD patients, 50 unaffected first-degree relatives of OCD patients, and 130 healthy comparison participants. Family history information indicated, that 76 healthy controls were free of a family history for psychopathology, whereas the remaining had first-degree relatives with depression (n = 28), anxiety (n = 27), and/or SUD (n = 27).
Increased ERN amplitudes were found in OCD patients and unaffected first-degree relatives of OCD patients. In addition, unaffected first-degree relatives of individuals with anxiety disorders were also characterized by increased ERN amplitudes, whereas relatives of individuals with SUD showed reduced amplitudes.
Alterations in neural error-signals in unaffected first-degree relatives with a family history of OCD, anxiety, or SUD support the utility of the ERN as a transdiagnostic endophenotype. Reduced neural error-signals may indicate vulnerability for under-controlled behavior and risk for substance use, whereas a harm- or error-avoidant response style and vulnerability for OCD and anxiety appears to be associated with increased ERN. This adds to findings suggesting a common neurobiological substrate across psychiatric disorders involving the anterior cingulate cortex and deficits in cognitive control.
To determine whether assignment to a multiple-bed room increased the risk of hospital-onset C. difficile diarrhea (HO-CDI).
San Francisco General Hospital and Trauma Center.
Adult general medical and surgical inpatients.
Consecutive cases of HO-CDI were identified between January 1, 2010, and December 31, 2015. To investigate the effect of multiple-bed room exposure both at admission and at the time of symptom onset, 2 sets of controls were selected from the general medical/surgical inpatient population using incidence density sampling. Conditional logistic regression was used to estimate the relationship between room assignment (single bed vs multiple beds) and the development of HO-CDI.
In total, 187 cases were identified and matched with 512 and 515 controls for the admission and at-diagnosis analyses, respectively. The adjusted rate ratio (RR) associated with the development HO-CDI associated with multiple-bed room exposure during the 7 and 14 days immediately prior to HO-CDI diagnosis were 1.08 (95% confidence interval [CI], 0.93–1.25; P=.31) and 0.96 (95% CI, 0.93–1.18; P=.12), respectively. Furthermore, no significant association was detected in the analysis of the first 7 and 14 days after case admission or among patients with Charlson comorbidity scores ≥4 in either period.
Assignment of patients to multiple-bed rooms on general medical and surgical wards was not associated with an increased risk in the development of HO-CDI. Future investigation should be performed with larger cohorts in multiple sites to more definitively address the question because this issue could have implications for patient room assignment and hospital design.
The Accountability for Reasonableness (A4R) framework addresses the legitimacy of coverage decision processes by defining four conditions for accountable and reasonable processes: Relevance, Publicity, Appeals, Implementation. Cost-per-quality-adjusted life year (QALY) and multicriteria-centered processes may have distinct implications for meeting A4R conditions. The aim of this study was to reflect on how the diverse features of decision-making processes can be aligned with A4R conditions to guide legitimized decision-making. Rare disease and regenerative therapies (RDRTs) pose special decision-making challenges and offer a useful case study.
To support reflection on how different approaches address the A4R conditions, thirty-four features operationalizing each condition were defined and organized into a matrix. Seven experts from six countries explored and discussed these features during a panel (Chatham House Rule) and provided general and RDRT-specific recommendations for each feature. Responses were analyzed to identify converging and diverging recommendations.
Regarding Relevance, panelists highlighted the importance of supporting deliberation, stakeholder participation and grounding coverage decision criteria in the legal framework, goals of sustainable healthcare and population values. Among seventeen criteria, thirteen were recommended by more than half of panelists. Although the cost-effectiveness ratio was deemed sometimes useful, the validity of universal thresholds to inform allocative efficiency was challenged. Regarding Publicity, panelists recommended communicating the values underlying a decision in reference to broader societal objectives, and being transparent about value judgements in selecting evidence. For Appeals, recommendations included clear definition of new evidence and revision rules. For Implementation, one recommendation was to perform external quality reviews of decisions. While RDRTs raise issues that may warrant special consideration, rarity should be considered in interaction with other aspects (e.g. disease severity, age, budget impact).
Improving coverage decision-making towards accountability and reasonableness involves supporting participation and deliberation, enhancing transparency, and more explicit consideration of multiple decision criteria that reflect normative and societal objectives.
Subjective cognitive decline (SCD), the potentially earliest notable manifestation of preclinical Alzheimer's disease and other dementias, was consistently associated with lower quality of life in cross-sectional studies. The aim of this study was to investigate whether such an association persists longitudinally – particularly with health-related quality of life (HRQoL) in older individuals without cognitive impairment.
Data were derived from follow-up 2–6 of the prospective Germany Study on Ageing, Cognition and Dementia in Primary Care (AgeCoDe) covering a total six-year observation period. We used linear mixed effects models to estimate the effect of SCD on HRQoL measured by the EQ-5D visual analogue scale (EQ VAS).
Of 1,387 cognitively unimpaired individuals aged 82.2 years (SD = 3.2) on average, 702 (50.6%) reported SCD and 230 (16.6%) with SCD-related concerns. Effect estimates of the linear mixed effects models revealed lower HRQoL in individuals with SCD (unadjusted: –3.7 points on the EQ VAS, 95%CI = –5.3 to –2.1; SE = 0.8; p < 0.001; adjusted: –2.9 points, 95%CI = –3.9 to –1.9; SE = 0.5; p < 0.001) than in individuals without SCD. The effect was most pronounced in SCD with related concerns (unadjusted: –5.4, 95%CI = –7.6 to –3.2; SE = 1.1; p < 0.001; adjusted: –4.3, 95%CI = –5.8 to –2.9, SE = 0.7; p < 0.001).
SCD constitutes a serious issue to older cognitively unimpaired individuals that is depicted in persisting lower levels of HRQoL beyond depressive symptoms and functional impairment. Therefore, SCD should be taken seriously in clinical practice.
Carbapenem-resistant Enterobacteriaceae (CRE) are a significant clinical and public health concern. Understanding the distribution of CRE colonization and developing a coordinated approach are key components of control efforts. The prevalence of CRE in the District of Columbia is unknown. We sought to determine the CRE colonization prevalence within healthcare facilities (HCFs) in the District of Columbia using a collaborative, regional approach.
This study included 16 HCFs in the District of Columbia: all 8 acute-care hospitals (ACHs), 5 of 19 skilled nursing facilities, 2 (both) long-term acute-care facilities, and 1 (the sole) inpatient rehabilitation facility.
Inpatients on all units excluding psychiatry and obstetrics-gynecology.
CRE identification was performed on perianal swab samples using real-time polymerase chain reaction, culture, and antimicrobial susceptibility testing (AST). Prevalence was calculated by facility and unit type as the number of patients with a positive result divided by the total number tested. Prevalence ratios were compared using the Poisson distribution.
Of 1,022 completed tests, 53 samples tested positive for CRE, yielding a prevalence of 5.2% (95% CI, 3.9%–6.8%). Of 726 tests from ACHs, 36 (5.0%; 95% CI, 3.5%–6.9%) were positive. Of 244 tests from long-term-care facilities, 17 (7.0%; 95% CI, 4.1%–11.2%) were positive. The relative prevalence ratios by facility type were 0.9 (95% CI, 0.5–1.5) and 1.5 (95% CI, 0.9–2.6), respectively. No CRE were identified from the inpatient rehabilitation facility.
A baseline CRE prevalence was established, revealing endemicity across healthcare settings in the District of Columbia. Our study establishes a framework for interfacility collaboration to reduce CRE transmission and infection.
When using bifunctional core@shell catalysts, the stability of both the shell and core–shell interface is crucial for catalytic applications. In the present study, we elucidate the stability of a CuO/ZnO/Al2O3@ZSM-5 core@shell material, used for one-stage synthesis of dimethyl ether from synthesis gas. The catalyst stability was studied in a hierarchical manner by complementary environmental transmission electron microscopy (ETEM), scanning electron microscopy (SEM) and in situ hard X-ray ptychography with a specially designed in situ cell. Both reductive activation and reoxidation were applied. The core–shell interface was found to be stable during reducing and oxidizing treatment at 250°C as observed by ETEM and in situ X-ray ptychography, although strong changes occurred in the core on a 10 nm scale due to the reduction of copper oxide to metallic copper particles. At 350°C, in situ X-ray ptychography indicated the occurrence of structural changes also on the µm scale, i.e. the core material and parts of the shell undergo restructuring. Nevertheless, the crucial core–shell interface required for full bifunctionality appeared to remain stable. This study demonstrates the potential of these correlative in situ microscopy techniques for hierarchically designed catalysts.
The Dietary Inflammatory Index (DII)TM, which was developed to characterize the inflammatory potential of a person’s diet, has been shown to be associated with inflammatory conditions such as cancer. The present study aimed to investigate the association between DII scores and colorectal adenoma (CRA), a pre-cancerous condition.
Responses to baseline dietary questionnaires were used calculate DII scores. In a cross-sectional study design, the association between DII scores and CRA prevalence was determined in men and women separately using logistic regression models.
Ten cancer screening centres across the USA.
Participants were those included in the screening arm of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial.
Among the 44 278 individuals included in these analyses, men with diets in the most inflammatory quartile of DII scores had higher odds of all types of CRA (advanced, non-advanced and multiple (>1)) compared with those with diets in the least inflammatory quartile of DII scores. In fully adjusted models, compared with those with DII scores in quartile 1 (least inflammatory), males with DII scores in quartile 3 (adjusted odds ratio (aOR)=1·28; 95 % CI 1·12, 1·47) and quartile 4 (aOR=1·41; 95 % CI 1·23, 1·62) were more likely to have prevalent distal CRA. Higher DII scores, representing a more inflammatory diet, also were weakly associated with a higher prevalence of CRA in women.
Implementing an anti-inflammatory diet may be an effective means of primary prevention of CRA, especially in men.
Most of the previous studies attempted to disentangle the relationship between disability and depressive symptoms were limited to observation periods of only few years. Moreover, evidence is missing regarding the complex co-occurrence of disability and depressive symptoms in old age in Germany. In order to close the research gap, we aimed at disentangling the complex co-occurrence of disability and depressive symptoms in old age in Germany over a longer time frame.
Based on data from a representative survey of the German general population aged 75 years and older, the course of disability as well as depressive symptoms was observed every 1.5 years over six waves. While disability was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale, the Geriatric Depression Scale was used to measure depressive symptoms. Taking into account the complex co-occurrence of depressive symptoms and disability, a panel vector autoregressive model was used. By taking the first differences, unobserved heterogeneity was taken into account.
In the total sample and in both sexes, we revealed a robust positive association between an initial change in depressive symptoms and subsequent changes in disability. No robust association between an initial change in disability and a subsequent change in depressive symptoms was detected.
Our findings highlight the importance of changes in depressive symptoms for future changes in disability in old age.
Child conduct problems (CP) reflect a heterogeneous collection of oppositional, aggressive, norm-violating, and sometimes violent behaviors, whereas child callous–unemotional (CU) behaviors reflect interpersonal styles of interactions reflecting a lack of guilt and empathy as well as uncaring and shallow emotional responses to others. Taken together, high levels of child CP and CU behaviors are thought to identify a relatively homogenous group of children at elevated risk for persistent and more severe problem behaviors across childhood and into adulthood. Although a large body of research has examined the developmental etiology of CP behaviors, only recently has a developmental psychopathology approach been applied to early CU behaviors. The current study examines multiple levels of contextual influences during the first years of life, including family socioeconomic status, household chaos, and parenting behaviors, on CP and CU behaviors assessed during the first-grade year. Whereas previous studies found associations between parenting behaviors and child problem behaviors moderated by household chaos, the current study found no evidence of moderation. However, path analyses suggest that the associations between child CP and CU behaviors and the contextual variables of socioeconomic status (family income and parental education) and household chaos (disorganization and instability) were mediated by maternal sensitive and harsh–intrusive parenting behavior. Analyses are presented, interpreted, and discussed with respect to both bioecological and family stress models of development.
We embed a critique of the respective strengths and weaknesses of policy initiatives to ‘build the rule of law’ within the broader literature on political settlements and developmental states, thereby creating a foundation for an alternative framework that takes politics and the legitimacy of change processes seriously. Thus far the dominant terms of debate have been between those advocating or resisting the replication of legal ‘forms’ (i.e., what modern legal institutions, statutes and procedures ‘look like’, such as constitutions) via large, rapid, imported technocratic interventions, and those pushing instead for a focus on enhancing a prevailing legal system's ‘functionality’ (what the existing system actually ‘does’) via a series of local level legal empowerment programs or attempts to redefine state-society relations by adjusting legal configurations. We argue for the inclusion of a third dimension, namely one encompassing procedural legitimacy and equitable contestation as part of the change process.