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Surgical site infections (SSIs) occur more frequently during periods of warmer temperatures. We aimed to investigate for which pathogens this association is particularly strong.
A retrospective observational study was conducted.
Data from the SSI-module of the German nosocomial infection surveillance system between 2000 and 2016 were linked with data from the German Meteorological Service. Patient- and procedure-related data were associated with monthly aggregated meteorological data. Due to high correlation with other meteorological parameters, we focused on the outside temperature. Adjusted odds ratios were calculated for SSI rates relating to temperature. SSIs were stratified by pathogen. A P value of <.05 was considered significant.
Altogether, 2,004,793 procedures resulting in 32,118 SSIs were included. Generally, warmer temperatures were associated with a higher SSI risk, especially for SSIs with gram-negative pathogens. This association was particularly prominent for Acinetobacter spp, Pseudomonas aeruginosa, and certain Enterobacteriaceae. Per additional 1°C, we observed a 6% increase in the SSI risk for Acinetobacter spp and a 4% increase for Enterobacter spp. Superficial SSIs with Acinetobacter spp were 10 times more likely to occur when comparing surgeries in months with mean temperatures of ≥20°C to mean temperatures of <5°C.
Higher temperatures were associated with increased SSI rates caused by gram-negative bacteria. Future SSI prevention measures should consider this aspect. Underlying shifts in microbiome composition due to climate factors should be included in further analyses. Given the expected rise of global temperatures until the end of the century, this topic has relevance from multiple perspectives.
Background: Various studies have linked periods of warmer temperatures to an increased occurrence of surgical site infections (SSIs) and healthcare-associated infections in general. In an observational study, we sought to determine the pathogens for which this association was especially strong. Method: Patient- and procedure-related data of the SSI-module of the German nosocomial infection surveillance system were linked with monthly aggregated meteorological data from the German Meteorological Service for a period from 2000 to 2016. Due to high correlation with other meteorological parameters, analyses were executed focusing on the outside ambient temperature. Temperature was regarded as both a continuous variable and a categorical variable with different temperature intervals (5°C steps ranging from <5°C to ≥20°C). Through multivariable logistic regression analysis, adjusted odds ratios (OR) with 95% confidence intervals were calculated for SSI rates relating to temperature. SSIs were stratified by pathogen and depth of infiltration. Result: Altogether, 2,004,793 procedures, conducted in 1,455 German surgical departments and resulting in 32,118 SSIs, were included. A general association of warmer mean temperatures in the month of surgery with an increased SSI-risk was observed, particularly for SSIs caused by gram-negative pathogens. Stratification by pathogen revealed that the association was especially prominent for Acinetobacter spp, Pseudomonas aeruginosa, and certain Enterobacteriaceae. Per additional 1°C, we observed a 6% increase in the risk for SSIs caused by Acinetobacter spp (OR, 1.06; 95% CI, 1.04–1.09), and a 4% increase in the risk for SSIs caused by Enterobacter spp (OR, 1.04; 95% CI, 1.03–1.05). Among gram-positive pathogens, temperature-association was strongest for Staphylococcus aureus. Superficial SSIs showed a higher temperature-association than deeper SSIs. The risk for superficial SSIs with Acinetobacter spp significantly increased >10-fold after surgeries conducted in months with a mean temperature of ≥20°C in reference to <5°C. For Pseudomonas aeruginosa, we observed a >2-fold statistically significant increase in the risk for superficial SSIs, when comparing the same temperature categories (≥20°C vs <5°C). Conclusions: Our study demonstrated that higher temperatures were associated with increased SSI-rates caused by gram-negative bacteria. As a consequence, future SSI-prevention measures should place a higher emphasis on the parameter season as part of a more tailormade, personalized approach at infection prevention. For instance, it may be conceivable to seasonally adjust decolonizing regimes and certain prophylaxes. Underlying shifts in microbiome composition due to meteorological factors should be considered in further analyses. Given the expected rise of global temperatures until the end of the century, the topic gains relevance from multiple perspectives.
The use of decision-making capacity assessments (DMCA) in clinical medicine is an underdeveloped yet quickly growing practice. Despite the ethical and clinical importance of these assessments as a means of protecting patient autonomy, clinicians, philosophers, and ethicists have identified a number of practical and theoretical hurdles which remain unresolved. One ethically important yet largely unaddressed issue is whether, and to what extent physicians ought to inform and obtain consent from patients prior to initiating a capacity assessment. In what follows, I address the following question: Must, or should, physicians obtain consent for capacity assessments? I argue that physicians have an ethical obligation to obtain express patient consent for capacity assessments, and in doing so, I challenge the predominant view which requires physicians to merely inform patients without obtaining consent. I then identify an underlying philosophical paradox that complicates the clinician's duty to obtain consent: in short, consent is needed for an assessment of one's ability to consent. Finally, I recommend a practical solution to this paradox of consent for capacity assessments by proposing a model of double consent from both the patient and health care representative.
This article focuses on how people who formerly worked as bonded labourers adapt to the new realities of an insecure capitalist labour market. It examines how the past shapes the uncertain labour situation of the present, including resistance. The article reflects on the current experiences of precarious labour at industrial sites in western Nepal. It describes how former bonded labourers and their descendants have begun working as contract workers in a modern industrial food-processing factory, with the help of contractors related to them by kin. The article further shows that one of the defining features of their new life as contract labourers is its chronic precariousness. Undisguised forms of confrontation, such as open disregard for management instructions, are also part of their new reality in the labour market. Contract labourers are often strongly assertive in the face of managerial authority, and this assertiveness has been shaped largely by either past experiences or memories of bonded labour. The article contributes to debates about bonded labour and its transformations in South Asia. It also offers a reflection on the limited impact of the Nepali Maoist Revolution on precarious labour and on the ethnic dimensions of this segment of Nepali society. Finally, it contributes to discussions about industrialization and Adivasi communities in South Asia and beyond.
In her article ‘Connecting the past and the present’, Meike Pentrel examines the order of main clause and adverbial clause introduced by before or after in Samuel Pepys's diary from the point of view of the cognitive literature on processing constraints. The thread that is shared by all contributions of this special issue is that of the hypothesis of uniformitarianism, which states that cognitive processes have remained constant in the documented history of humanity. Pentrel aims at corroborating this hypothesis by testing if the processing constraints found at work in this seventeenth-century ego-document examined by her are similar to those that have been observed in contemporary language.
This article combines methodologies from corpus linguistics with an experimental-like setup more affiliated to psycholinguistic research. The resulting methodology allows us to gain more insight into cognitive motivations of language use in speakers from the past, and consequently to better assess their similarity to present-day speakers (the Uniformitarian Principle). One such cognitive motivation thought to be relevant in the early stages of grammatical constructionalization (grammaticalization) is covered by the evasive concept of ‘extravagance’ (i.e. the desire to talk in such a way that one is noticed). The methodology is tested on the Early Modern English extension of the [be Ving]-construction to progressive uses in present-tense main clauses. It is argued, on the basis of recurrent contextual clues, that [be Ving] in this novel use is motivated by extravagance. Interestingly, a comparison of two speaker/writer generations that are among the earliest to use this innovation with some frequency suggests that the encoding of extravagance shifted between them. At first, extravagance was signalled by coercion of the still stative semantics of [be Ving] into a progressive reading. In the second generation it had become an entrenched characteristic of the construction itself.
Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment.
Key informant survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs’ attitude of “trying to establish a diagnosis of dementia on their own.”
Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28–5.23).
Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.
Ernietta plateauensis Pflug, 1966 is the type species of the Erniettomorpha, an extinct clade of Ediacaran life. It was likely a gregarious, partially infaunal organism. Despite its ecological and taxonomic significance, there has not been an in-depth systematic description in the literature since the original description fell out of use. A newly discovered field site on Farm Aar in southern Namibia has yielded dozens of specimens buried in original life position. Mudstone and sandstone features associated with the fossils indicate that organisms were buried while still exposed to the water column rather than deposited in a flow event. Ernietta plateauensis was a sac-shaped erniettomorph with a body wall constructed from a double layer of tubes. It possessed an equatorial seam lying perpendicular to the tubes. The body is asymmetrical on either side of this seam. The tubes change direction along the body length and appear to be constricted together in the dorsal part of the organism.
Whose responsibility is it to tackle climate change? ‘Everyone’s and no one’s’, we might glibly reply. Responsibility is diffused across scales, social groups, sectors, countries and generations. The causes of climate change are implicated in everyday acts of production and consumption and relate to the ways in which societies organise their transportation, housing, energy, water and food systems. Recognising the complex and diffuse agencies and authorities that address climate change, the world of climate politics is no longer limited to the activities of national governments, international organisations and interstate bargaining between states. Increasingly, subnational governments, non-governmental organisations, businesses and individuals are taking responsibility into their own hands, experimenting with bold new approaches to the governance of climate change (Betsill & Bulkeley 2004; Andonova, Betsill & Bulkeley 2009; Selin & VanDeveer 2009b; Bulkeley & Newell 2010; Hoffmann 2011; Bulkeley et al. 2013). The governance of climate change now takes a seemingly bewildering array of forms: carbon markets, certification standards, voluntary workplace schemes, emissions registries, carbon labelling, urban planning codes and so on. Critical to this transformation of the politics of climate change has been the emergence of new forms of transnational governance that cut across traditional state-based jurisdictions, operate across public-private divides and seek to develop new approaches and techniques through which responses are developed. What sets these initiatives apart from other forms of transnational relations is how they not only influence others, but also how they directly intervene in the governing of global affairs in ways that defy conventional understandings of international relations.
This chapter examines the political dynamics underpinning the emergence of TCCG. In the first section of the chapter, we undertake a temporal analysis of the growth of TCCG, focusing on its parallel evolution with the international climate change regime and the broader political-economic shifts outlined in the previous chapter. In the second section of the chapter, our analysis turns to consider the patterns and drivers of private, hybrid and public transnational initiatives over time and to consider the governance functions that are being pursued in these different forms of TCCG. Through this analysis, we seek to capture the process through which climate politics has pluralised by describing and offering explanations for the growth of institutional diversity over time.
In doing so, the three theoretical lenses discussed in Chapter 3 serve as guides for our analysis. The agency-centred perspective is particularly helpful for highlighting the interests of the actors that populate climate politics, their sources of influence and factors underpinning the demand and supply of new forms of transnational governance. The social and system dynamics perspective helps to explain the diffusion of common practices and governance techniques through communities of environmental practitioners and policymakers. Finally, the critical political theory perspective sheds light on the marketisation of a substantial cluster of TCCG initiatives, the ideological underpinnings of these initiatives and the particular constellations of public and private forces that animate them. We use the TCCG database and illustrative case-studies to interrogate these issues illuminating the relationship between the agency of different actors, market logics, functional imperatives and normative contexts.
Our knowledge of transnational governance has been fundamentally shaped by the theoretical perspectives and methodological approaches that have been used to study it (O’Neill et al. 2013, 444). Primarily using a case-study approach revolving around a few high-profile examples, research on transnational governance has focused on the ways in which actors have sought to engage with different forms of transnational governance, the various functions that such arrangements seek to perform and their potential consequences in terms of legitimacy and effectiveness. Such approaches have yielded significant insights into these aspects of transnational governance but cannot, by their very nature, achieve a more comprehensive or systematic view. As O’Neill et al. (2013) suggest, such approaches may be ill-equipped to deal with the challenges of ‘complexity and uncertainty, vertical linkages across multiple scales, horizontal linkages across issue areas, and (often rapidly) evolving problem sets and institutional initiatives’ that beset global environmental governance research, such that new methodological approaches are required. If we regard transnational governance initiatives as having something in common – in terms of what they are seeking to accomplish, or in terms of the ways in which they are organised and constituted – we suggest that methodological innovations capable of creating a more comprehensive account of the overall phenomenon are required.
In order to develop such a broader understanding of the extent and nature of transnational governance in the climate change domain, our approach extends beyond small n case-studies or surveys of one particular type of transnational arrangement through the construction and analysis of a database of sixty transnational climate governance initiatives. This approach enables an analysis of the contours of transnational climate governance in a way that has not been possible within existing methodological approaches, allowing for a more thorough description of who and what are involved, where it is taking place, and how and why it is being pursued.
One thing should already be clear from the preceding chapters: transnational climate governance is qualitatively different from the standard multilateral model that has characterised the last two decades of climate change governance. The multilateral model is a hierarchical one; it functions through the generally accepted legitimate authority of nation-states to act on issues that transcend borders. In the multilateral process, a legally binding global treaty engages all nation-states in a common (and hopefully enforceable) purpose. In theory, there is an assumption of smooth vertical development of policy that draws on the legitimate, traditional authority of nation-states, both in constructing the international treaty and formulating national regulations. International law translates to national regulation, which directs domestic actions at more local levels. Alternatives to the authority and legitimacy of the multilateral process are rarely considered quite simply because the global system has functioned through this process for over a century (Denemark & Hoffmann 2008) despite criticisms about the interests served by this system and whose order it seeks to preserve (Cox 1987; Murphy 1994; Cox & Sinclair 1996). The emergence and functioning of TCCG asks us to question and engage questions of authority and legitimacy with a more critical eye, to understand how, in Hajer’s (2003) words, we can have policy without a polity, or how, as Rosenau asks, a range of actors can govern without the legal authority to do so (Rosenau & Czempiel 1992).