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Psychiatric disorders, including eating disorders (EDs), have clinical outcomes that range widely in severity and chronicity. The ability to predict such outcomes is extremely limited. Machine-learning (ML) approaches that model complexity may optimize the prediction of multifaceted psychiatric behaviors. However, the investigations of many psychiatric concerns have not capitalized on ML to improve prognosis. This study conducted the first comparison of an ML approach (elastic net regularized logistic regression) to traditional regression to longitudinally predict ED outcomes.
Females with heterogeneous ED diagnoses completed demographic and psychiatric assessments at baseline (n = 415) and Year 1 (n = 320) and 2 (n = 277) follow-ups. Elastic net and traditional logistic regression models comprising the same baseline variables were compared in ability to longitudinally predict ED diagnosis, binge eating, compensatory behavior, and underweight BMI at Years 1 and 2.
Elastic net models had higher accuracy for all outcomes at Years 1 and 2 [average Area Under the Receiving Operating Characteristics Curve (AUC) = 0.78] compared to logistic regression (average AUC = 0.67). Model performance did not deteriorate when the most important predictor was removed or an alternative ML algorithm (random forests) was applied. Baseline ED (e.g. diagnosis), psychiatric (e.g. hospitalization), and demographic (e.g. ethnicity) characteristics emerged as important predictors in exploratory predictor importance analyses.
ML algorithms can enhance the prediction of ED symptoms for 2 years and may identify important risk markers. The superior accuracy of ML for predicting complex outcomes suggests that these approaches may ultimately aid in advancing precision medicine for serious psychiatric disorders.
China has the largest population of elderly citizens in the world, with 177 million adults aged 60 years or older. However, no national estimate of malnutrition in elderly Chinese adults exists. We estimated the prevalence and predictors of malnutrition in this population.
Data from the second wave of the Chinese Health and Retirement Longitudinal Study (CHARLS) include interview and biomarker data for 6450 subjects aged 60 years or older from 448 different communities in twenty-eight provinces, allowing for nationally representative results. Malnutrition was identified based on the ESPEN (European Society of Parenteral and Enteral Nutrition and Metabolism) criteria. We used multivariable regression to investigate the predictors of malnutrition, including demographic factors, marital status, self-reported health status, self-reported standard of living, health insurance status and education.
Community-dwelling Chinese adults aged 60 years or older.
The prevalence of malnutrition in elderly Chinese adults was 12·6 %. Malnutrition was most common among those who were older (OR=1·09; 95 % CI 1·07, 1·10), male (OR=1·41; 95 % CI 1·10, 1·79), lived in rural areas (v. urban: OR=0·75; 95 % CI 0·57, 1·00) or lacked health insurance (P<0·01).
The burden of malnutrition on elderly Chinese adults is significant. Based on current population estimates, up to 20 million are malnourished. Malnutrition is strongly associated with demographic factors, shows a trend to association with health status and is not strongly associated with standard of living or education. A coordinated effort is needed to address malnutrition in this population.
Burnt mounds, or fulachtaí fiadh as they are known in Ireland, are probably the most common prehistoric site type in Ireland and Britain. Typically Middle–Late Bronze Age in age (although both earlier and later examples are known), they are artefact-poor and rarely associated with settlements. The function of these sites has been much debated with the most commonly cited uses being for cooking, as steam baths or saunas, for brewing, tanning, or textile processing. A number of major infrastructural development schemes in Ireland in the years 2002–2007 revealed remarkable numbers of these mounds often associated with wood-lined troughs, many of which were extremely well-preserved. This afforded an opportunity to investigate them as landscape features using environmental techniques – specifically plant macrofossils and charcoal, pollen, beetles, and multi-element analyses. This paper summarises the results from eight sites from Ireland and compares them with burnt mound sites in Great Britain. The fulachtaí fiadh which are generally in clusters, are all groundwater-fed by springs, along floodplains and at the bases of slopes. The sites are associated with the clearance of wet woodland for fuel; most had evidence of nearby agriculture and all revealed low levels of grazing. Multi-element analysis at two sites revealed elevated heavy metal concentrations suggesting that off-site soil, ash or urine had been used in the trough. Overall the evidence suggests that the most likely function for these sites is textile production involving both cleaning and/or dyeing of wool and/or natural plant fibres and as a functionally related activity to hide cleaning and tanning. Whilst further research is clearly needed to confirm if fulachtaí fiadh are part of the ‘textile revolution’ we should also recognise their important role in the rapid deforestation of the wetter parts of primary woodland and the expansion of agriculture into marginal areas during the Irish and British Bronze Ages.
The history of international law is often told in terms of the rise and fall of great powers or as a mechanism of colonial subjugation. To the extent that these accounts consider justice, it is usually to demonstrate its absence. This paper points out that justice has been integral to the evolution of international law in the era of the United States. Individuals and members of civil society in the US and Europe have influenced systemic developments in international law through their efforts to realize a vision of justice in interstate relations, their vision being of a body of international law and a world court which together obviate the need for war. To suggest the possibility of an historical narrative constructed around justice is not to deny the validity of other histories focused on inequitable relations of power, but to point to the scope for nuance in the frameworks within which we portray international law and its history.
For centuries nations have struggled among each other. But we dream of a world where disputes are settled by law and reason. And we will try to make it so.
Lyndon Johnson, 1965
Critical to the US pursuit of legal security has been its involvement with the evolution of what could be referred to as systemic regimes of international law – those relating to the making and enforcement of, and the resolution of disputes in, international law – in an attempt to ensure that the principles, rules, and concepts that constitute those regimes facilitate the US pursuit of legal security. It is arguable that US engagement with the development of codified legal regimes addressing systemic elements of international law tells us more about the US attitude to international law per se than do its actions in relation to specific subject areas addressed by international law, such as human rights, in which it is sometimes difficult to distinguish the nature of the US attitude towards international law from US policy in the particular issue area. This chapter is devoted to the nature of US engagement with the evolution of the law pertaining to dispute resolution in public international law. It will trace US participation in the evolution of treaty law relating to third-party dispute resolution, from its earliest involvement in international arbitration to its more recent stance regarding a permanent international court and a legalized process of third-party dispute resolution in the World Trade Organization (WTO), to reveal a remarkable degree of consistency.
The United States, since its formation, has led in promoting a reign of law and justice as between nations.
John Foster Dulles, 1946
Much of this book has focused on US involvement in the development of specific regimes of international law. We have seen that the United States has worked hard to get favourable systemic rules in place as well as taking extreme care with the detail of the specific substantive legal obligations it has assumed or not assumed. We have briefly considered a range of techniques that has facilitated the United States succeeding on many occasions – although no claim has been made that the United States has always been able to get all that it wanted in terms of the content of international law. Promoting an ideal of international law has gone some way towards masking the instrumental use of international law on the part of the United States. This chapter will explore ways in which the United States has invoked international law in its diplomacy, a subject that has been inadequately analysed by the scholarly community. This is the dimension of the US quest for legal security in which there has possibly been the greatest variation over time.
The political sway of international law
The fact that so much of this book has focused on the systemic and substantive content of international law begs the question of what the point is of US officials paying such close attention to the specific obligations assumed or not assumed by it and others. One possible reply to this is: ‘Not very much; international law in any case lacks effective enforcement mechanisms. The United States seems to have disregarded international law when it wanted to, and so have others. It does not really seem to have mattered to the United States whether international law prohibited the use of force, and those who have been subjected to US attack were not saved by Article 2(4).’ This response is unconvincing. If international law had been considered of such little consequence it is highly doubtful that the United States would have invested so heavily in the system and its evolution. One does not have to claim that the United States has always complied with its international law obligations to acknowledge the seriousness with which the United States regards legal obligations and the prevalence of law in the conduct of its foreign relations.
The more I study the history of American foreign policy, the more deeply convinced I become that our national foreign policy tradition has much to teach us. We don’t just draw lucky cards; we also play the game well. Over two hundred years we have developed our own unique style, which suits us. Certainly it has enabled us to become the richest and most powerful nation in the history of the world.
Walter Russell Mead, 2001
It has often been observed that the United States is a country built on law. Justice Anthony Kennedy has noted that Americans were given ‘a self image, a self identification, a self understanding about who they are’ from the Declaration of Independence and the Constitution. Rivkin and Casey referred to the United States as ‘a nation bound together not by ties of blood or religion, but by paper and ink’. Paul Kahn has described the importance of law to the national sense of identity; according to Kahn it is participation in the legal system that unites the United States into a single community. ‘The rule of law, for us, is not simply a matter of getting the content of rights correct. It is first of all an expression of our sense of ourselves as a single, historical community engaging in self-government through law.’ According to Allott, ‘American law is not merely one social system among many. It is the central instrument of the self-constituting of American society.’
Some observers of the predominant place of law in US culture believe that law provides a kind of ‘cultural glue’, binding together a diverse nation and ‘serving as a focus of values and aspirations that define the American people’.
It is not just that the legal dimension of affairs is particularly prominent in the United States, not just that people turn to the courts more often, on more matters, than elsewhere. Americans turn to the courts with a particular kind of faith, and hope, which survives at a deep level despite all the disappointments and frustrations of the legal process.
As the patriots of seventy-six did to the support of the Declaration of Independence, so to the support of the Constitution and Laws, let every American pledge his life, his property, and his sacred honor; – let every man remember that to violate the law, is to trample on the blood of his father, and to tear the character of his own, and his children’s liberty . . . let [a reverence for the laws] become the political religion of the nation; and let the old and the young, the rich and the poor, the grave and the gay, of all sexes and tongues, and colors and conditions, sacrifice unceasingly upon its altars.
While ever a state of feeling, such as this shall universally, or even, very generally prevail throughout the nation, vain will be every effort, and fruitless every attempt, to subvert our national freedom.
Abraham Lincoln, 1838
The United States has an expansionist history. Within the same continent at first, and then abroad, the United States continued to extend its reach until it was the predominant power globally and in space. War was key to the rise of the United States, whether that be through avoiding a European war, or fighting and winning. Even the Civil War (1861–5) ‘assured that the United States would become a “great power” capable of leading the “free world”’. And yet the United States was able to develop a global projection of power largely without being recognized as imperial or expansionist. The rise of the United States was accompanied by what Andrew Bacevich has referred to as the myth of the reluctant superpower. ‘Some nations may be said to be born to power; others achieve power, or try to. Of the United States alone can it truly be said that power has been thrust upon her?’ According to the myth, the United States has only ever reluctantly been drawn into war by external factors, and only ‘inadvertently’ acquired an empire.
‘Without this unqualified right of appeal to arms no nation can be independent’.
Senate Committee on Foreign Relations, Minority Report on the Olney-Pauncefote Treaty, 1897
The US quest for legal security, understood as the safeguarding of US law and policies from external influences via international law while using international law to impact on the law and policy choices of other states, has been integral to the US pursuit of traditional, or military, security. The international law addressing the use of force has been a key regime by which to ensure that the US enjoys a structural advantage in the international system. As with participation in the evolving regime of third-party international dispute resolution, US policymakers have shown a high degree of consistency in the nature of their engagement with the evolving regime relating to the use of force. It is worth examining this consistency in some detail because it has been so critical to the achievement of US objectives, and US decision-makers have certainly paid close attention to the detail of the relevant law.
US decision-makers would not ever have considered surrendering decision-making regarding the use of force. It has been deemed vital that the United States retain the freedom to use its military only when it perceived it as in its interests to do so, not assuming any obligation to use force ahead of an actual scenario. For international law to evolve so as to prevent the United States using force should it wish to do so would likewise have been regarded as a severe incursion on US legal security. Once there were restrictions on the use of force in international law, it would also have been unthinkable for the United States to accept a situation in which other states had a legal right to use force against it. This chapter will trace US involvement in the evolution of treaty law related to the use of force, demonstrating the high degree of continuity in positions adopted by the United States and the manner in which those positions have underpinned its legal and military security.
For the United States, an essential element of the rule of law has always been, and still remains, law among nations. We’ve always respected our international legal obligations and we have led the world in developing new international law . . . . [W]e try and use our great power not to win glory or imperial gain for ourselves but to establish international rules and norms that we encourage others to follow.
Condoleezza Rice, 2005
The US pursuit of legal security has involved an offensive dimension, by which the United States has sought to influence the international law undertakings as well as the domestic laws and policies of other states, as well as a defensive dimension, by which the United States has sought to safeguard its own legal position against interference by others via law. The pursuit of legal security is not, however, an end in itself but an avenue by which the United States can pursue its policy objectives more broadly, including in the economic, military, environmental, and social fields. The vehicles for the pursuit of legal security in specific substantive areas of US policy have evolved during the life of the United States. US legislation itself has been used on occasion, as well as the bilateral treaty and, in recent years, resolutions of the Security Council. But it is the multilateral treaty that is most distinctive of the American age. The era of the multilateral treaty coincides with that of the United States as a great power; the first multilateral lawmaking conferences, multilateral treaties, and intergovernmental organizations (IGOs) appeared in the second half of the nineteenth century.
The United States used multilateral treaties in the immediate post-Second World War years to establish a system of international institutions, characterized by John Ikenberry as ‘liberal hegemony’. A number of the multilateral treaties most fundamental to the post-Second World War international order were drafted in the United States, with US interests in mind. Institutions that could be regarded as foundational to the post-war international order in whose design the US took a lead include the United Nations, GATT, the International Monetary Fund, the World Bank, and the Treaty on the Non-Proliferation of Nuclear Weapons.