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Accelerating COVID-19 Treatment Interventions and Vaccines (ACTIV) was initiated by the US government to rapidly develop and test vaccines and therapeutics against COVID-19 in 2020. The ACTIV Therapeutics-Clinical Working Group selected ACTIV trial teams and clinical networks to expeditiously develop and launch master protocols based on therapeutic targets and patient populations. The suite of clinical trials was designed to collectively inform therapeutic care for COVID-19 outpatient, inpatient, and intensive care populations globally. In this report, we highlight challenges, strategies, and solutions around clinical protocol development and regulatory approval to document our experience and propose plans for future similar healthcare emergencies.
During the 2018 K$\unicode{x012B}$lauea lower East Rift Zone eruption, lava from 24 fissures inundated more than 8000 acres of land, destroying more than 700 structures over three months. Eruptive activity eventually focused at a single vent characterized by a continuously fed lava pond that was drained by a narrow spillway into a much wider, slower channelized flow. The spillway exhibited intervals of ‘pulsing’ behaviour in which the lava depth and velocity were observed to oscillate on time scales of several minutes. At the time, this was attributed to variations in vesiculation originating at depth. Here, we construct a toy fluid dynamical model of the pond–spillway system, and present an alternative hypothesis in which pulsing is generated at the surface, within this system. We posit that the appearance of pulsing is due to a supercritical Hopf bifurcation driven by an increase in the Reynolds number. Asymptotics for the limit cycle near the bifurcation point are derived with averaging methods and compare favourably with the cycle periodicity. Because oscillations in the pond were not observable directly due to the elevation of the cone rim and an obscuring volcanic plume, we model the observations using a spatially averaged Saint-Venant model of the spillway forced by the pond oscillator. The predicted spillway cycle periodicity and waveforms compare favourably with observations made during the eruption. The unusually well-documented nature of this eruption enables estimation of the viscosity of the erupting lava.
Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system.
Methods:
This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated.
Results:
A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt.
Conclusion:
Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.
Despite the growing availability of sensing and data in general, we remain unable to fully characterize many in-service engineering systems and structures from a purely data-driven approach. The vast data and resources available to capture human activity are unmatched in our engineered world, and, even in cases where data could be referred to as “big,” they will rarely hold information across operational windows or life spans. This paper pursues the combination of machine learning technology and physics-based reasoning to enhance our ability to make predictive models with limited data. By explicitly linking the physics-based view of stochastic processes with a data-based regression approach, a derivation path for a spectrum of possible Gaussian process models is introduced and used to highlight how and where different levels of expert knowledge of a system is likely best exploited. Each of the models highlighted in the spectrum have been explored in different ways across communities; novel examples in a structural assessment context here demonstrate how these approaches can significantly reduce reliance on expensive data collection. The increased interpretability of the models shown is another important consideration and benefit in this context.
There is insufficient evidence to support the pharmacological treatment of borderline personality disorder. However, previous out-patient cohorts have described high rates of polypharmacy in this group. So far, there have been no national studies that have considered polypharmacy in borderline personality disorder.
Aims
To describe psychotropic polypharmacy in people with borderline personality disorder in New Zealand.
Method
New Zealand's national databases have been used to link psychotropic medication dispensing data and diagnostic data for borderline personality disorder. Annual dispensing data for 2014 and 2019 have been compared.
Results
Fifty percent of people with borderline personality disorder who were dispensed medications had three or more psychotropic medications in 2014. This increased to 55.9% in 2019 (P < 0.001). Those on seven or more psychotropics increased from 8.4 to 10.7% (P < 0.023). Quetiapine was the most dispensed psychotropic medication, being given to 53.8% of people dispensed medication with borderline personality disorder in 2019. Lorazepam dispensing showed the largest increase, going from 15.5 to 26.7% between 2014 and 2019 (P < 0.001).
Conclusions
There is a large burden of psychotropic polypharmacy in people with borderline personality disorder. This is concerning because of the lack of evidence regarding the efficacy of these medications in this group.
The U.S. Department of Agriculture–Agricultural Research Service (USDA-ARS) has been a leader in weed science research covering topics ranging from the development and use of integrated weed management (IWM) tactics to basic mechanistic studies, including biotic resistance of desirable plant communities and herbicide resistance. ARS weed scientists have worked in agricultural and natural ecosystems, including agronomic and horticultural crops, pastures, forests, wild lands, aquatic habitats, wetlands, and riparian areas. Through strong partnerships with academia, state agencies, private industry, and numerous federal programs, ARS weed scientists have made contributions to discoveries in the newest fields of robotics and genetics, as well as the traditional and fundamental subjects of weed–crop competition and physiology and integration of weed control tactics and practices. Weed science at ARS is often overshadowed by other research topics; thus, few are aware of the long history of ARS weed science and its important contributions. This review is the result of a symposium held at the Weed Science Society of America’s 62nd Annual Meeting in 2022 that included 10 separate presentations in a virtual Weed Science Webinar Series. The overarching themes of management tactics (IWM, biological control, and automation), basic mechanisms (competition, invasive plant genetics, and herbicide resistance), and ecosystem impacts (invasive plant spread, climate change, conservation, and restoration) represent core ARS weed science research that is dynamic and efficacious and has been a significant component of the agency’s national and international efforts. This review highlights current studies and future directions that exemplify the science and collaborative relationships both within and outside ARS. Given the constraints of weeds and invasive plants on all aspects of food, feed, and fiber systems, there is an acknowledged need to face new challenges, including agriculture and natural resources sustainability, economic resilience and reliability, and societal health and well-being.
We present the third data release from the Parkes Pulsar Timing Array (PPTA) project. The release contains observations of 32 pulsars obtained using the 64-m Parkes ‘Murriyang’ radio telescope. The data span is up to 18 yr with a typical cadence of 3 weeks. This data release is formed by combining an updated version of our second data release with $\sim$3 yr of more recent data primarily obtained using an ultra-wide-bandwidth receiver system that operates between 704 and 4032 MHz. We provide calibrated pulse profiles, flux density dynamic spectra, pulse times of arrival, and initial pulsar timing models. We describe methods for processing such wide-bandwidth observations and compare this data release with our previous release.
Understanding the distribution and extent of suitable habitats is critical for the conservation of endangered and endemic taxa. Such knowledge is limited for many Central African species, including the rare and globally threatened Grey-necked Picathartes Picathartes oreas, one of only two species in the family Picathartidae endemic to the forests of Central Africa. Despite growing concerns about land-use change resulting in fragmentation and loss of forest cover in the region, neither the extent of suitable habitat nor the potential species’ distribution is well known. We combine 339 (new and historical) occurrence records of Grey-necked Picathartes with environmental variables to model the potential global distribution. We used a Maximum Entropy modelling approach that accounted for sampling bias. Our model suggests that Grey-necked Picathartes distribution is strongly associated with steeper slopes and high levels of forest cover, while bioclimatic, vegetation health, and habitat condition variables were all excluded from the final model. We predicted 17,327 km2 of suitable habitat for the species, of which only 2,490 km2 (14.4%) are within protected areas where conservation designations are strictly enforced. These findings show a smaller global distribution of predicted suitable habitat forthe Grey-necked Picathartes than previously thought. This work provides evidence to inform a revision of the International Union for Conservation of Nature (IUCN) Red List status, and may warrant upgrading the status of the species from “Near Threatened” to “Vulnerable”.
The hypothesis that violence—especially gang violence—behaves like a contagious disease has grown in popularity in recent years. Scholars have long observed the tendency for violence to cluster in time and space, but little research has focused on empirically unpacking the mechanisms that make violence contagious. In the context of gang violence, retaliation is the prototypical mechanism to explain why violence begets violence. In this study, we leverage relational event models (REMs)—an underutilized yet particularly well-suited modeling technique to study the dynamics of inter-gang violence. We use REMs to examine gang violence’s tendency to replicate—for which retaliation is but one plausible mechanism—and its tendency to diffuse to other groups. We rely on data on conflicts between gangs in a region of Los Angeles over 3 years. We consider how the characteristics of gangs, their spatial proximity, networks of established rivalries, and the evolving history, directionality, and structure of conflicts predict future inter-gang conflicts. While retaliation is an important mechanism for the replication of violence, established rivalries, and inertia—a gang’s tendency to continue attacking the same group—are more important drivers of future violence. We also find little evidence for an emerging pecking order or status hierarchy between gangs suggested by other scholars. However, we find that gangs are more likely to attack multiple gangs in quick succession. We propose that gang violence is more likely to diffuse to other groups because of the boost of internal group processes an initial attack provides.
Approximately 80 million people live with chronic hepatitis B virus (HBV) infection in the WHO Africa Region. The natural history of HBV infection in this population is poorly characterised, and may differ from patterns observed elsewhere due to differences in prevailing genotypes, environmental exposures, co-infections, and host genetics. Existing research is largely drawn from small, single-centre cohorts, with limited follow-up time. The Hepatitis B in Africa Collaborative Network (HEPSANET) was established in 2022 to harmonise the process of ongoing data collection, analysis, and dissemination from 13 collaborating HBV cohorts in eight African countries. Research priorities for the next 5 years were agreed upon through a modified Delphi survey prior to baseline data analysis being conducted. Baseline data on 4,173 participants with chronic HBV mono-infection were collected, of whom 38.3% were women and the median age was 34 years (interquartile range 28–42). In total, 81.3% of cases were identified through testing of asymptomatic individuals. HBeAg-positivity was seen in 9.6% of participants. Follow-up of HEPSANET participants will generate evidence to improve the diagnosis and management of HBV in this region.
In Iran, studies of the transition from hunting and gathering to farming and herding have focused on early developments in the Zagros Mountains. Here, the authors present new zooarchaeological data from Hotu Cave, which throw light on sheep/goat management and domestication during the Epipalaeolithic–Neolithic transition on the southern shores of the Caspian Sea. Gazelle dominate the Epipalaeolithic levels, while sheep/goat are most abundant in the Neolithic. Large quantities of perinatal sheep/goat remains from the Early Neolithic indicate that these animals were actively managed in or close to the cave. The results point towards the importance in Iran of local developments beyond the Zagros, adding nuance to the general model of domestication in South-west Asia.
Broiler chickens are the most numerous terrestrial farmed animals on earth. These birds can suffer a range of pathologies which result in lameness, and one technique for assessing the impact of lameness on the individual bird, and on the flock has been gait scoring. This paper describes a study where the results of the same training programme for validated gait scoring are compared for groups of assessors in Thailand, Brazil and New Zealand. A uniform course of training carried out in the classroom, through video assessment and through on-farm training was carried out in the countries named; a total of 95 persons being trained overall. A measure of agreement with the reference scale for the assessors' numerical responses was carried out using a Cohen's Kappa test, and the results indicated significant differences in the ‘origin position’ ie the view taken by the assessors of the impact of lameness on the bird before training had taken place, but a high degree of consistency in the response to training. The study demonstrated that gait scoring can be learned by assessors from different geographical and social backgrounds, and that the ‘rate of learning’ – the improvement in performance in relation to a standard, was similar between the countries studied. The ‘origin’ and ‘final’ position of the assessors pre- and post-training, from the different countries in relation to the reference standard is discussed.
This book provides one of the first assessments of the widely used but extremely controversial Anti-Social Behaviour Orders (ASBOs) as a method for dealing with anti-social behaviour in the UK.
Animal and human data demonstrate independent relationships between fetal growth, hypothalamic-pituitary-adrenal axis function (HPA-A) and adult cardiometabolic outcomes. While the association between fetal growth and adult cardiometabolic outcomes is well-established, the role of the HPA-A in these relationships is unclear. This study aims to determine whether HPA-A function mediates or moderates this relationship. Approximately 2900 pregnant women were recruited between 1989-1991 in the Raine Study. Detailed anthropometric data was collected at birth (per cent optimal birthweight [POBW]). The Trier Social Stress Test was administered to the offspring (Generation 2; Gen2) at 18 years; HPA-A responses were determined (reactive responders [RR], anticipatory responders [AR] and non-responders [NR]). Cardiometabolic parameters (BMI, systolic BP [sBP] and LDL cholesterol) were measured at 20 years. Regression modelling demonstrated linear associations between POBW and BMI and sBP; quadratic associations were observed for LDL cholesterol. For every 10% increase in POBW, there was a 0.54 unit increase in BMI (standard error [SE] 0.15) and a 0.65 unit decrease in sBP (SE 0.34). The interaction between participant’s fetal growth and HPA-A phenotype was strongest for sBP in young adulthood. Interactions for BMI and LDL-C were non-significant. Decomposition of the total effect revealed no causal evidence of mediation or moderation.
Evidence for risk of dying by suicide and other causes following discharge from in-patient psychiatric care throughout adulthood is sparse.
Aims
To estimate risks of all-cause mortality, natural and external-cause deaths, suicide and accidental, alcohol-specific and drug-related deaths in working-age and older adults within a year post-discharge.
Method
Using interlinked general practice, hospital, and mortality records in the Clinical Practice Research Datalink we delineated a cohort of discharged adults in England, 2001–2018. Each patient was matched to up to 20 general population comparator patients. Cumulative incidence (absolute risks) and hazard ratios (relative risks) were estimated separately for ages 18–64 and ≥65 years with additional stratification by gender and practice-level deprivation.
Results
The 1-year cumulative incidence of dying post-discharge was 2.1% among working-age adults (95% CI 2.0–2.3) and 14.1% (95% CI 13.6–14.5) among older adults. Suicide risk was particularly elevated in the first 3 months, with hazard ratios of 191.1 (95% CI 125.0–292.0) among working-age adults and 125.4 (95% CI 52.6–298.9) in older adults. Older patients were vulnerable to dying by natural causes within 3 months post-discharge. Risk of dying by external causes was greater among discharged working-age adults in the least deprived areas. Relative risk of suicide in discharged working-age women relative to their general population peers was double the equivalent male risk elevation.
Conclusions
Recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first 3 months post-discharge.
Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out ‘organic’ causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment.
Catatonia, a severe neuropsychiatric syndrome, has few studies of sufficient scale to clarify its epidemiology or pathophysiology. We aimed to characterise demographic associations, peripheral inflammatory markers and outcome of catatonia.
Methods
Electronic healthcare records were searched for validated clinical diagnoses of catatonia. In a case–control study, demographics and inflammatory markers were compared in psychiatric inpatients with and without catatonia. In a cohort study, the two groups were compared in terms of their duration of admission and mortality.
Results
We identified 1456 patients with catatonia (of whom 25.1% had two or more episodes) and 24 956 psychiatric inpatients without catatonia. Incidence was 10.6 episodes of catatonia per 100 000 person-years. Patients with and without catatonia were similar in sex, younger and more likely to be of Black ethnicity. Serum iron was reduced in patients with catatonia [11.6 v. 14.2 μmol/L, odds ratio (OR) 0.65 (95% confidence interval (CI) 0.45–0.95), p = 0.03] and creatine kinase was raised [2545 v. 459 IU/L, OR 1.53 (95% CI 1.29–1.81), p < 0.001], but there was no difference in C-reactive protein or white cell count. N-Methyl-d-aspartate receptor antibodies were significantly associated with catatonia, but there were small numbers of positive results. Duration of hospitalisation was greater in the catatonia group (median: 43 v. 25 days), but there was no difference in mortality after adjustment.
Conclusions
In the largest clinical study of catatonia, we found catatonia occurred in approximately 1 per 10 000 person-years. Evidence for a proinflammatory state was mixed. Catatonia was associated with prolonged inpatient admission but not with increased mortality.
Knotweed (Fallopia spp.) is an herbaceous perennial from East Asia that was brought to Europe and North America and, despite control efforts, subsequently spread aggressively on both continents. Data are available on knotweed’s modes of sexual and asexual spread, historical spread, preferred habitat, and ploidy levels. Incomplete information is available on knotweed’s current global geographic distribution and genetic diversity. The chemical composition of knotweed leaves and rhizomes has been partially discovered as related to its ability to inhibit growth and germination of neighboring plant communities via phytochemicals. There is still critical information missing. There are currently no studies detailing knotweed male and female fertility. Specifically, information on pollen viability would be important for further understanding sexual reproduction as a vector of spread in knotweed. This information would help managers determine the potential magnitude of knotweed sexual reproduction and the continued spread of diverse hybrid swarms. The potential range of knotweed and its ability to spread into diverse habitats makes studies on knotweed seed and rhizome cold tolerance of utmost importance, yet to date no such studies have been conducted. There is also a lack of genetic information available on knotweed in the upper Midwest. Detailed genetic information, such as ploidy levels and levels of genetic diversity, would answer many questions about knotweed in Minnesota, including understanding its means of spread, what species are present in what densities, and current levels of hybridization. This literature review summarizes current literature on knotweed to better understand its invasiveness and to highlight necessary future research that would benefit and inform knotweed management in the upper Midwest.
Psychosis is a major mental illness with first onset in young adults. The prognosis is poor in around half of the people affected, and difficult to predict. The few tools available to predict prognosis have major weaknesses which limit their use in clinical practice. We aimed to develop and validate a risk prediction model of symptom non-remission in first-episode psychosis.
Method
Our development cohort consisted of 1027 patients with first-episode psychosis recruited between 2005 to 2010 from 14 early intervention services across the National Health Service in England. Our validation cohort consisted of 399 patients with first-episode psychosis recruited between 2006 to 2009 from a further 11 English early intervention services. The one-year non-remission rate was 52% and 54% in the development and validation cohorts, respectively. Multivariable logistic regression was used to develop a risk prediction model for non-remission, which was externally validated.
Result
The prediction model showed good discrimination (C-statistic of 0.74 (0.72, 0.76) and adequate calibration with intercept alpha of 0.13 (0.03, 0.23) and slope beta of 0.99 (0.87, 1.12). Our model improved the net-benefit by 16% at a risk threshold of 50%, equivalent to 16 more detected non-remitted first-episode psychosis individuals per 100 without incorrectly classifying remitted cases.
Conclusion
Once prospectively validated, our first episode psychosis prediction model could help identify patients at increased risk of non-remission at initial clinical contact.