To save 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 saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
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 saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved 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.
A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap.
Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. “Consensus” was defined as ≥ 80% of responses as “agree” or “strongly agree” to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not.
The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for “low” and “high” volume patients, and timing and duration of fat-modified diet. All recommendations achieved “consensus” (agreement >80%) by the workgroup (range 81–100%). Ex vivo simulations demonstrated good understanding by developers (range 94–100%) and non-developers (73%–100%).
The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.
The Centers for Medicare and Medicaid mandated that nursing homes implement antibiotic stewardship programs (ASPs) by November 2017. We conducted surveys of Wisconsin nursing-home stewardship practices before and after this mandate. Our comparison of these surveys shows an overall increase in ASP implementation efforts, but it also highlights areas for further improvement.
Response to lithium in patients with bipolar disorder is associated with clinical and transdiagnostic genetic factors. The predictive combination of these variables might help clinicians better predict which patients will respond to lithium treatment.
To use a combination of transdiagnostic genetic and clinical factors to predict lithium response in patients with bipolar disorder.
This study utilised genetic and clinical data (n = 1034) collected as part of the International Consortium on Lithium Genetics (ConLi+Gen) project. Polygenic risk scores (PRS) were computed for schizophrenia and major depressive disorder, and then combined with clinical variables using a cross-validated machine-learning regression approach. Unimodal, multimodal and genetically stratified models were trained and validated using ridge, elastic net and random forest regression on 692 patients with bipolar disorder from ten study sites using leave-site-out cross-validation. All models were then tested on an independent test set of 342 patients. The best performing models were then tested in a classification framework.
The best performing linear model explained 5.1% (P = 0.0001) of variance in lithium response and was composed of clinical variables, PRS variables and interaction terms between them. The best performing non-linear model used only clinical variables and explained 8.1% (P = 0.0001) of variance in lithium response. A priori genomic stratification improved non-linear model performance to 13.7% (P = 0.0001) and improved the binary classification of lithium response. This model stratified patients based on their meta-polygenic loadings for major depressive disorder and schizophrenia and was then trained using clinical data.
Using PRS to first stratify patients genetically and then train machine-learning models with clinical predictors led to large improvements in lithium response prediction. When used with other PRS and biological markers in the future this approach may help inform which patients are most likely to respond to lithium treatment.
The world has surpassed three million deaths from COVID-19, and faces potentially catastrophic tipping points in the global climate system. Despite the urgency, governments have struggled to address either problem. In this paper, we argue that COVID-19 and anthropogenic climate change (ACC) are critical examples of an emerging type of governance challenge: severe collective action problems that require significant individual behavior change under conditions of hyper-partisanship and scientific misinformation. Building on foundational political science work demonstrating the potential for norms (or informal rules of behavior) to solve collective action problems, we analyze more recent work on norms from neighboring disciplines to offer novel recommendations for more difficult challenges like COVID-19 and ACC. Key insights include more attention to 1) norm-based messaging strategies that appeal to individuals across the ideological spectrum or that reframe collective action as consistent with resistant subgroups’ pre-existing values, 2) messages that emphasize both the prevalence and the social desirability of individual behaviors required to address these challenges, 3) careful use of public policies and incentives that make individual behavior change easier without threatening norm internalization, and 4) greater attention to epistemic norms governing trust in different information sources. We conclude by pointing out that COVID-19 and climate change are likely harbingers of other polarized collective action problems that governments will face in the future. By connecting work on norms and political governance with a broader, interdisciplinary literature on norm psychology, motivation, and behavior change, we aim to improve the ability of political scientists and policymakers to respond to these and future collective action challenges.
Coronary artery aneurysms are well-described in Kawasaki disease and the Multisystem Inflammatory Syndrome in Children and are graded using Z scores. Three Z score systems (Boston, Montreal, and DC) are widely used in North America. The recent Pediatric Heart Network Z score system is derived from the largest diverse sample to-date. The impact of Z score system on the rate of coronary dilation and management was assessed in a large real-world dataset.
Using a combined dataset of patients with acute Kawasaki disease from the Children’s Hospital at Montefiore and the National Heart, Lung, and Blood Institute Kawasaki Disease Study, coronary Z scores and the rate of coronary lesions (Z ≥ 2.0) and aneurysms (Z ≥ 2.5) were determined using four Z score systems. Agreement among Z scores and the effect on Kawasaki management were assessed.
Of 333 patients analysed, 136 were from Montefiore and 197 from the Kawasaki Disease Study. Age, sex, body surface area, and rate of coronary lesions did not differ between the samples. Among the four Z score systems, the rate of acute coronary lesions varied from 24 to 55%. The mean left anterior descending Z scores from Pediatric Heart Network and Boston had a large uniform discrepancy of 1.3. Differences in Z scores among the four systems may change anticoagulation management in up to 22% of a Kawasaki population.
Choice of Z score system alone may impact Kawasaki disease diagnosis and management. Further research is necessary to determine the ideal coronary Z score system.
The prominence of poetry and other kinds of literary work in which the skill displayed in the writing contends for attention with the work’s contents was an outstanding feature of Judeo-Arabic society in our period and one that distinguishes this society from all earlier and most succeeding Jewish societies until the nineteenth century. Arabic-speaking Jewish writers, in the period covered by this volume, produced literary works of lasting appeal not only because some were profound thinkers, sensitive souls, or linguistically gifted individuals, but because Arabo-Islamic society created institutions in which artistic writing played an important public role, thereby encouraging the cultivation of elegant language and literary craftsmanship among its subject peoples as well. Poetry and fine writing were first and foremost instruments of public life and secondarily of upper-class social life and entertainment. The literary forms cultivated for these purposes were vehicles for the expression of communal attitudes as well as individual writers’ personal views and even inner experience. The age of Judeo-Arabic ascendancy produced, for the first time in Jewish history, something we can recognize as literature, in the artistic sense of the word.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
Previous study demonstrates that partisans perceive in-party news outlets as fair, and out-party news outlets as unfair. However, much of this study relies on one-shot designs. We create an ecologically valid design that randomly assigns participants to news feeds within a week-long online news portal where the balance of in-party and out-party news outlets has been manipulated. We find that sustained exposure to a feed that features out-party news media attenuates Democrats' beliefs that Fox News is unfair, but the same is not true for Republican's perceptions of MSNBC's fairness. Unexpectedly, repeated exposure to in-party news did increase Republicans' beliefs that Fox News is unfair. This study updates our understanding of partisan news effects in a fragmented online news environment.
We report infrared reflectance and ultraviolet fluorescence spectra of the surfaces and cleaved side of Beacon Sandstone from Antarctica that harbours a cryptoendolithic microbial community - a photosynthesis-based consortium of algae, lichen and bacteria present a few millimetres below the surface. Chlorophyll absorptions were present in the reflectance spectra of the exposed interior but not on the top or bottom surfaces and their band depths changed < 4% between measurements taken 19 years apart, indicating the stability of the microorganisms when the sample is kept dry. The presence of subsurface organic layers was detected in reflectance at 3.41 μm on the sample's surface. Fluorescence spectra of the cleaved side showed the blue fluorescence peaks expected from chlorophyll but no 0.65–0.80 μm peaks seen in fluorescence measurements of green vegetation. A weak fluorescence signal was detectable at the surface of the sample, presumably due to some light leaking into the subsurface through pores or cracks in the goethite coating the sample's surface. Theoretically, this weak fluorescence signal could possibly be observed in rock surfaces broken by erosion or meteor impacts on Mars. Sandstone outcrops have been reported on Mars and detection of organic layers in sandstones there would be of interest.
On May 11, the Dutch Government allowed 26 nursing homes to welcome 1 visitor per resident, after 2 months of lockdown. The study aimed to monitor in-depth the feasibility of the regulations and their impact on the well-being of residents, their visitors, and healthcare staff.
Mixed-methods study in 5 of the 26 facilities; the facilities were affiliated to an academic network of nursing homes.
Visitors and healthcare professionals.
Allowing visitors using local regulations based on national guidelines.
Digital questionnaire, analyzing documentation such as infection prevention control protocols, attending meetings of COVID-19 crisis teams, in-depth telephone or in-person interviews with visitors and healthcare professionals, and on-site observations.
National guidelines were translated with great variety into local care practice. Healthcare professionals agreed that reopening would increase the well-being of the residents and their loved ones. However, there were also great worries for increasing workload, increasing the risk of emotional exhaustion, and the risk of COVID-19 infections. Compliance with local regulations was generally satisfactory, but maintaining social distance and correctly wearing face masks appeared to be difficult. Care staff remained ambivalent for fear of infections. In general, allowing visitors was experienced as having a positive impact on the well-being of all stakeholders. Nevertheless, some residents with dementia showed negative effects.
The complete lockdown of Dutch nursing homes had a substantial impact on the well-being of the residents. The reopening was welcomed by all stakeholders, but provided a high organizational workload as well as feelings of ambivalence among care staff. In the second wave, a more tailored approach is being implemented. However, facilities are sometimes still struggling to find the right balance between infection control and well-being.
Whole-genome sequencing confirmed the presence of a Malassezia pachydermatis outbreak among neonates in a neonatal intensive care unit. This technology supports the importance of adhering to infection prevention measures.
The personality traits of neuroticism, openness, and conscientiousness are relevant factors for cognitive aging outcomes. The present study examined how these traits were associated with cognitive abilities and corresponding resting-state functional connectivity (RSFC) of the default mode network (DMN) in an older and predominantly minority sample. A sample of 58 cognitively unimpaired, largely African-American, older adults (M age = 68.28 ± 8.33) completed a standard RSFC magnetic resonance imaging sequence, a Big Five measure of personality, and delayed memory, Stroop, and verbal fluency tasks. Personality trait associations of within-network connectivity of the posterior cingulate cortex (PCC), a hub of the DMN, were examined using a seed-based approach. Trait scores were regressed on cognitive performance (delayed memory for neuroticism, Stroop for conscientiousness, and verbal fluency for openness). Greater openness predicted greater verbal fluency and greater RSFC between the PCC and eight clusters, including the medial prefrontal cortex, left middle frontal gyrus, and precuneus. Greater PCC–precuneus connectivity predicted greater verbal fluency. Neuroticism and conscientiousness did not significantly predict either cognitive performance or RSFC. Although requiring replication and elaboration, the results implicate openness as a contributing factor to cognitive aging via concomitant cognitive performance and connectivity within cortical hubs of the DMN and add to the sparse literature on these variables in a diverse group of older adults.
We developed an expensiveness index and used the Food Acquisition and Purchase Survey data set to examine empirically whether Supplemental Nutrition Assistance Program (SNAP) participants pay higher prices compared with nonqualifying and qualifying, but nonparticipating, households. Purchasers’ ability to minimize food expenditures has significant effects on the program’s effectiveness and on participants’ food security. Using ordinary least squares and two techniques that control for the endogeneity of SNAP participation, we found no significant effect of SNAP participation on food prices. Moreover, we found that SNAP participants pay, on average, lower prices than do nonparticipants. We conclude by providing suggestions for policy improvements and implications for future research.
President Donald Trump faced substantial scandal coverage early in his presidency. Can these stories about presidential controversies change the opinions of Trump’s fellow Republicans, or are the efforts of the news media to inform partisans about prominent issues futile? Past research on partisan reactions to major political scandals were confounded by problems with self-reported media use and single-shot experimental treatments. We address these concerns using a unique, repeated-exposure experimental design that either randomly supplied participants with news about the Trump-Russia scandal, or removed most of those stories from view, over the course of one week in June 2017. This design mimics sustained media attention to a political scandal and disentangles the effects of media coverage from selection in the context of a high-choice media environment. We find that Republicans randomly assigned to see more Trump-Russia headlines reacted more negatively than Democrats or Independents, rating Trump’s performance lower and expressing more negative emotions about him. Republicans’ perceptions of media bias were not affected by Trump-Russia stories, and effects were not contingent upon clicking the articles. Intense media focus on a story can alter partisans’ evaluations of politicians by shifting the balance of headlines.
We collected dietary records over the course of nine months to comprehensively characterize the consumption patterns of Malagasy people living in remote rainforest areas of north-eastern Madagascar.
The present study was a prospective longitudinal cohort study to estimate dietary diversity and nutrient intake for a suite of macronutrients, micronutrients and vitamins for 152 randomly selected households in two communities.
Madagascar, with over 25 million people living in an area the size of France, faces a multitude of nutritional challenges. Micronutrient-poor staples, especially rice, roots and tubers, comprise nearly 80 % of the Malagasy diet by weight. The remaining dietary components (including wild foods and animal-source foods) are critical for nutrition. We focus our study in north-eastern Madagascar, characterized by access to rainforest, rice paddies and local agriculture.
We enrolled men, women and children of both sexes and all ages in a randomized sample of households in two communities.
Although the Household Dietary Diversity Score and Food Consumption Score reflect high dietary diversity, the Minimum Dietary Diversity–Women indicator suggests poor micronutrient adequacy. The food intake data confirm a mixed nutritional picture. We found that the median individual consumed less than 50 % of his/her age/sex-specific Estimated Average Requirement (EAR) for vitamins A, B12, D and E, and Ca, and less than 100 % of his/her EAR for energy, riboflavin, folate and Na.
Malnutrition in remote communities of north-eastern Madagascar is pervasive and multidimensional, indicating an urgent need for comprehensive public health and development interventions focused on providing nutritional security.
Medical issues facing the aging population are of growing concern with consequences for patients and their caregivers. This study determined the indirect and out-of-pocket costs incurred by the caregivers of elderly patients in Canadian Intensive Care Units (ICUs). Primary family caregivers were surveyed capturing out-of-pocket costs, hours of work, and hours of leisure forgone in providing patient care while the patient was in the ICU. Total costs of care per month were reported across caregiver sex, age, and geographic region. Average out-of-pocket costs were $791 (2016 Canadian dollars) in the first month of ICU care. The mean total cost to family caregivers per patient was $162 per day. Male primary caregivers had higher mean out-of-pocket costs than female caregivers. Subsidization programs covering expenses such as travel, meals, accommodation, and parking are needed to support family caregivers of elderly ICU patients who are incurring considerable out-of-pocket costs.
We examine whether speed is an important characteristic of traders who anticipate local price trends. These anticipatory participants correctly trade prior to the overall market and systematically act before other participants. They use manual and algorithmic order entry methods, but most are not fast enough to be high frequency traders (HFTs). Those anticipating price trends have impacts as if they are informed traders, while the case for anticipatory participants affecting the volume of other traders is rejected. A follow-up sample shows significant attrition in accounts and difficulty maintaining the anticipatory strategies. To identify anticipatory traders, we devise novel methods to isolate local price trends using order book data from the West Texas Intermediate (WTI) crude oil futures market.