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This chapter provides an overview of economic and behavioral economic approaches to behavior change. The chapter begins with a description of the traditional or neoclassical economic view of decision-making using expected utility theory as its basis. Attempts by an external party (e.g., a government or agency) to change behavior are viewed as justifiable in a limited number of circumstances, such as when there are externalities or coordination failures. When behavior change is warranted, neoclassical economics has focused on four options: provide information, increase incentives, reduce prices, or increase subsidies, or impose regulations. To be successful, the approach must change the net benefits of the promoted behavior. The chapter then describes the rationale behind behavioral economic approaches to behavior change, emphasizing the role that “nudges” play in behavior change. Examples are provided of common heuristics and associated decision errors that can result, and how nudges are designed to overcome these decision errors. The underlying rationale and steps for developing nudges are summarized. Current evidence suggests that some nudges can be effective in changing behavior, but more research is needed to demonstrate the effectiveness of many nudge strategies. The chapter concludes with a discussion of the likely long-term impact of nudges in the field of behavior change.
A primary barrier to translation of clinical research discoveries into care delivery and population health is the lack of sustainable infrastructure bringing researchers, policymakers, practitioners, and communities together to reduce silos in knowledge and action. As National Institutes of Healthʼs (NIH) mechanism to advance translational research, Clinical and Translational Science Award (CTSA) awardees are uniquely positioned to bridge this gap. Delivering on this promise requires sustained collaboration and alignment between research institutions and public health and healthcare programs and services. We describe the collaboration of seven CTSA hubs with city, county, and state healthcare and public health organizations striving to realize this vision together. Partnership representatives convened monthly to identify key components, common and unique themes, and barriers in academic–public collaborations. All partnerships aligned the activities of the CTSA programs with the needs of the city/county/state partners, by sharing resources, responding to real-time policy questions and training needs, promoting best practices, and advancing community-engaged research, and dissemination and implementation science to narrow the knowledge-to-practice gap. Barriers included competing priorities, differing timelines, bureaucratic hurdles, and unstable funding. Academic–public health/health system partnerships represent a unique and underutilized model with potential to enhance community and population health.
Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.
The Cavan–Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.
Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.
There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.
Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
The late Pleistocene–early Holocene archaeological record of the interior Pacific Northwest is dominated by what has been regionally referred to as the Western Stemmed Tradition (WST). While various efforts have attempted to clarify the chronology of this tradition, these have largely focused on data from the Great Basin and have been disproportionately preoccupied with establishing the beginning of the tradition due to its temporal overlap with Clovis materials. Specifically focusing on the Columbia Plateau, we apply a series of Bayesian chronological models to create concise estimates of the most likely beginning, end, and span of the WST. We then further explore its chronology by modeling its temporal span under various parameters and criteria so as to better identify places in the chronology that need further work and those that are robust regardless of data iteration. Our analysis revealed four major findings: (1) WST conservatively dates between 13,000 and 11,000 cal BP, likely extending to ~13,500 cal BP; (2) the most problematic period for WST is its termination; (3) the WST is incredibly long-lived compared to roughly contemporary Paleoindian traditions; and (4) the WST was seemingly unaffected by the onset of the Younger Dryas.
Background: Agenesis of the corpus callosum (AgCC) involves congenital absence of all or part of the corpus callosum. Because the disorder can only be firmly diagnosed via neuroradiology, it has a short research history, and only recently has the cognitive syndrome become clear. Purpose: Our purpose is to review the primary deficits in AgCC that constitute the core syndrome. Conclusions: The cores syndrome includes: (1) reduced interhemispheric transfer of sensory-motor information; (2) reduced cognitive processing speed; and (3) deficits in complex reasoning and novel problem-solving. These domains do not appear to reflect different neuroanatomical abnormalities, but rather different domains of expression of reduced interhemispheric communication from callosal absence. Implications: These core deficits are expressed across various domains of cognitive, behavioral, and social functioning. The impact of these deficits varies across development and may be moderated by individual factors such as co-occurrence of other neurodevelopmental conditions, general intellectual capacity, and environmental support. (JINS, 2019, 25, 324–330)
Induced abortion is an indicator of access to, and quality of reproductive healthcare, but rates are relatively unknown in women with schizophrenia.
We examined whether women with schizophrenia experience increased induced abortion compared with those without schizophrenia, and identified factors associated with induced abortion risk.
In a population-based, repeated cross-sectional study (2011–2013), we compared women with and without schizophrenia in Ontario, Canada on rates of induced abortions per 1000 women and per 1000 live births. We then followed a longitudinal cohort of women with schizophrenia aged 15–44 years (n = 11 149) from 2011, using modified Poisson regression to identify risk factors for induced abortion.
Women with schizophrenia had higher abortion rates than those without schizophrenia in all years (15.5–17.5 v. 12.8–13.6 per 1000 women; largest rate ratio, 1.33; 95% CI 1.16–1.54). They also had higher abortion ratios (592–736 v. 321–341 per 1000 live births; largest rate ratio, 2.25; 95% CI 1.96–2.59). Younger age (<25 years; adjusted relative risk (aRR), 1.84; 95% CI 1.39–2.44), multiparity (aRR 2.17, 95% CI 1.66–2.83), comorbid non-psychotic mental illness (aRR 2.15, 95% CI 1.34–3.46) and substance misuse disorders (aRR 1.85, 95% CI 1.47–2.34) were associated with increased abortion risk.
These results demonstrate vulnerability related to reproductive healthcare for women with schizophrenia. Evidence-based interventions to support optimal sexual health, particularly in young women, those with psychiatric and addiction comorbidity, and women who have already had a child, are warranted.
Self-harm in young people is associated with later problems in social and emotional development. However, it is unknown whether self-harm in young women continues to be a marker of vulnerability on becoming a parent. This study prospectively describes the associations between pre-conception self-harm, maternal depressive symptoms and mother–infant bonding problems.
The Victorian Intergenerational Health Cohort Study (VIHCS) is a follow-up to the Victorian Adolescent Health Cohort Study (VAHCS) in Australia. Socio-demographic and health variables were assessed at 10 time-points (waves) from ages 14 to 35, including self-reported self-harm at waves 3–9. VIHCS enrolment began in 2006 (when participants were aged 28–29 years), by contacting VAHCS women every 6 months to identify pregnancies over a 7-year period. Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale during the third trimester, and 2 and 12 months postpartum. Mother–infant bonding problems were assessed with the Postpartum Bonding Questionnaire at 2 and 12 months postpartum.
Five hundred sixty-four pregnancies from 384 women were included. One in 10 women (9.7%) reported pre-conception self-harm. Women who reported self-harming in young adulthood (ages 20–29) reported higher levels of perinatal depressive symptoms and mother–infant bonding problems at all perinatal time points [perinatal depressive symptoms adjusted β = 5.40, 95% confidence interval (CI) 3.42–7.39; mother–infant bonding problems adjusted β = 7.51, 95% CI 3.09–11.92]. There was no evidence that self-harm in adolescence (ages 15–17) was associated with either perinatal outcome.
Self-harm during young adulthood may be an indicator of future vulnerability to perinatal mental health and mother–infant bonding problems.
Tumor profiling tests can help to identify whether women with breast cancer need chemotherapy due to their risk of relapse, and some may be able to predict benefit from chemotherapy. We focused on four genetic tests: Oncotype DX (O-DX), MammaPrint (MMP), EndoPredict and Prosigna, and one immunohistochemistry test, IHC4, for the National Institute of Health and Care Excellence as part of their Diagnostic Appraisal Programme.
A systematic review was undertaken, including searching of nine databases in February 2017 plus other sources including a previous review published in 2013. The review included studies assessing clinical effectiveness of the five tumor profiling tests, with or without clinicopathological factors, to guide decisions about adjuvant chemotherapy in people with ER-positive, HER-2 negative, Stage I-II cancer with 0 to 3 positive lymph nodes (LN). The PROBAST tool and Cochrane risk of bias tools were used to assess risk of bias.
A total of 153 studies were included; the strength of evidence base for individual tests was varied. Results suggest all tests are prognostic for risk of relapse, though results were more varied in LN positive (+) patients than in LN negative (0) patients. Evidence was limited about whether tests can predict benefit from chemotherapy (available for MMP and O-DX only). Studies that assessed the impact of the tests on clinical decisions indicate that the net change in chemotherapy recommendations or decisions pre-/post-test ranged from an increase of one percent to a decrease of 23 percent among UK studies, and a decrease of zero percent to 64 percent across European studies.
The studies included in the review suggest that all of the tests can provide prognostic information on the risk of relapse; however results were more varied in LN+ patients than in LN0 patients. There is limited and varying evidence for prediction of chemotherapy benefit.
Tillage is a foundational management practice in many cropping systems. Although effective at reducing weed populations and preparing a crop seedbed, tillage and cultivation can also dramatically alter weed community composition. We examined the impact of soil tillage timing on weed community structure at four sites across the northeastern United States. Soil was tilled every 2 wk throughout the growing season (late April to late September 2013), and weed seedling density was quantified by species 6 wk after each tillage event. We used a randomized complete block design with four replicates for each tillage-timing treatment; a total of 196 plots were sampled. The timing of tillage was an important factor in shaping weed community composition and structure at all sites. We identified three main periods of tillage timing that resulted in similar communities. Across all sites, total weed density tended to be greatest and weed evenness tended to be lowest when soils were tilled early in the growing season. From the earliest to latest group of timings, total abundance decreased on average from 428±393 to 159±189 plants m−2, and evenness increased from 0.53±0.25 to 0.72±0.20. The effect of tillage timing on weed species richness varied by site. Our results show that tillage timing affects weed community structure, suggesting that farmers can manage weed communities and the potential for weed interference by adjusting the timing of their tillage and cropping practices.
RAVE is the spectroscopic survey with the largest overlap with TGAS (around 200000 stars). Since RAVE's fourth data release, it has contained distance estimates based on a Bayesian estimation scheme. Here we compare these estimates to TGAS's parallaxes, to determine the strengths and weaknesses of each. We also combine the two datasets together to find more precise distance estimates for all these stars.
Using RAVE data release 5 (DR5), we explore the age and chemistry of a sample of ~25,000 FGK turnoff stars in the extended solar neighbourhood (7 < R < 9 kpc), by separating our sample into two chemical disc components, and investigating the nature of the age-metallicity relation for both. Overall, we find a flat trend in [Fe/H] as a function of age for our α-low disc, and a correlation between age and metallicity for the oldest α-high stars, confirming age-metallicity trends found in more local, high-resolution studies now for a larger volume. We also find a positive gradient in [Mg/Fe] as a function of age for our oldest stars. These results have implications for models which include dynamical evolutionary processes such as radial migration.
We present an in-depth study of metal-poor stars, based high resolution spectra combined with newly released astrometric data from Gaia, with special attention to observational uncertainties. The results are compared to those of other studies, including Gaia benchmark stars. Chemical evolution models are discussed, highlighting few puzzles that are still affecting our understanding of stellar nucleosynthesis and of the evolution of our Galaxy.
We present our effort to measure the proper motions of satellites in the halo of the Milky Way with mainly ground based telescopes as a precursor on what is possible with Gaia. For our first study, we used wide field optical data from the LBT combined with a first epoch of SDSS observations, on the globular cluster Palomar 5 (Pal 5). Since Pal 5 is associated with a tidal stream it is very useful to constrain the shape of the potential of the Milky Way. The motion and other properties of the Pal 5 system constrain the inner halo of the Milky Way to be rather spherical. Further, we combined adaptive optics and HST to get an absolute proper motion of the globular cluster Pyxis. Using the proper motion and the line-of-sight velocity we find that the orbit of Pyxis is rather eccentric with its apocenter at more than 100 kpc and its pericenter at about 30 kpc. The dynamics excludes an association with the ATLAS stream, the Magellanic clouds, and all satellites of the Milky Way at least down to the mass of Leo II. However, the properties of Pyxis, like metallicity and age, point to an origin from a dwarf of at least the mass of Leo II. We therefore propose that Pyxis originated from an unknown relatively massive dwarf galaxy, which is likely today fully disrupted. Assuming that Pyxis is bound to the Milky Way we derive a 68% lower limit on the mass of the Milky Way of 9.5 × 1011 M⊙.
Older care home residents are excluded from the sexual imaginary. Based on a consultative study involving interviews with three residents, three female spouses of residents and two focus groups of care home staff (N = 16), making an overall sample of 22 study participants, we address the neglected subject of older residents' sexuality and intimacy needs. Using thematic analysis, we highlight how residents’ and spouses’ accounts of sexuality and intimacy can reflect an ageist erotophobia occurring within conditions of panoptical control that help construct residents as post-sexual. However, not all accounts contributed to making older residents’ sexuality appear invisible or pathological. Some stories indicated recuperation of identities and the normalisation of relationships with radically changed individuals, e.g. because of a dementia. We also examine care home staff accounts of the discursive obstacles that frustrate meeting residents’ needs connected with sexuality and intimacy. Simultaneously, we explore staffs’ creative responses to dilemmas which indicate approaches to sexuality driven more by observed needs than erotophobic anxiety and governance, as well as panoptical surveillance.
New paediatric cardiology trainees are required to rapidly assimilate knowledge and gain clinical skills to which they have limited or no exposure during residency. The Pediatric Cardiology Fellowship Boot Camp (PCBC) at Boston Children’s Hospital was designed to provide incoming fellows with an intensive exposure to congenital cardiac pathology and a broad overview of major areas of paediatric cardiology practice.
The PCBC curriculum was designed by core faculty in cardiac pathology, echocardiography, electrophysiology, interventional cardiology, exercise physiology, and cardiac intensive care. Individual faculty contributed learning objectives, which were refined by fellowship directors and used to build a programme of didactics, hands-on/simulation-based activities, and self-guided learning opportunities.
A total of 16 incoming fellows participated in the 4-week boot camp, with no concurrent clinical responsibilities, over 2 years. On the basis of pre- and post-PCBC surveys, 80% of trainees strongly agreed that they felt more prepared for clinical responsibilities, and a similar percentage felt that PCBC should be offered to future incoming fellows. Fellows showed significant increase in their confidence in all specific knowledge and skills related to the learning objectives. Fellows rated hands-on learning experiences and simulation-based exercises most highly.
We describe a novel 4-week-long boot camp designed to expose incoming paediatric cardiology fellows to the broad spectrum of knowledge and skills required for the practice of paediatric cardiology. The experience increased trainee confidence and sense of preparedness to begin fellowship-related responsibilities. Given that highly interactive activities were rated most highly, boot camps in paediatric cardiology should strongly emphasise these elements.