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To quantify the impact of clinical guidance and rapid respiratory and meningitis/encephalitis multiplex polymerase chain reaction (mPCR) testing on the management of infants.
Before-and-after intervention study.
Tertiary-care children’s hospital.
Infants ≤90 days old presenting with fever or hypothermia to the emergency department (ED).
The study spanned 3 periods: period 1, January 1, 2011, through December 31, 2014; period 2, January 1, 2015, through April 30, 2018; and period 3, May 1, 2018, through June 15, 2019. During period 1, no standardized clinical guideline had been established and no rapid pathogen testing was available. During period 2, a clinical guideline was implemented, but no rapid testing was available. During period 3, a guideline was in effect, plus mPCR testing using the BioFire FilmArray respiratory panel 2 (RP 2) and the meningitis encephalitis panel (MEP). Outcomes included antimicrobial and ancillary test utilization, length of stay (LOS), admission rate, 30-day mortality. Outcomes were compared across periods using Kruskal-Wallis and Pearson tests and interrupted time series analysis.
Overall 5,317 patients were included: 2,514 in period 1, 2,082 in period 2, and 721 in period 3. Over the entire study period, we detected reductions in the use of chest radiographs, lumbar punctures, LOS, and median antibiotic duration. After adjusting for temporal trends, we observed that the introduction of the guideline was associated with reductions in ancillary tests and lumbar punctures. Use of mPCR testing with the febrile infant clinical guideline was associated with additional reductions in ancillary testing for all patients and a higher proportion of infants 29–60 days old being managed without antibiotics.
Use of mPCR testing plus a guideline for young infant evaluation in the emergency department was associated with less antimicrobial and ancillary test utilization compared to the use of a guideline alone.
By the last quarter of the seventh century the Byzantine areas of Italy had experienced over a century of upheaval. Within decades of their first invasion of Italy in 568 the Lombards had established a powerful kingdom consisting of the territories north of the river Po, Tuscany and the two outlying duchies of Spoleto and Benevento. The empire was confined to the areas of Rome and its duchy, Ravenna, and the neighbouring areas of the exarchate and the Pentapolis, approximating to the present-day Romagna and Marche, and a few coastal areas elsewhere. The Byzantines had only been able to hold on to their possessions by initiating a thoroughgoing militarisation of society, which involved the concentration of land in military hands and the concentration of authority in the hands of the commander-in-chief in Ravenna (the exarch) and his subordinates (duces and magistri militum at a provincial level and tribuni in the localities). In many areas, such as the Roman Campania, this process was accompanied by a steady shift of population, as settlement became concentrated on military strongholds and refuges, usually located on promontories. Although the pressure eased somewhat in the seventh century, Liguria and most of the remaining settlements on the Venetian mainland were lost to the Lombards in the reign of King Rothari (636–52), and the duchy of Benevento made continual encroachments in the south, accelerating after the unsuccessful expedition of Emperor Constans II (641–68) to southern Italy in 663–8. Internal tensions were reflected in a series of revolts, the determined opposition led by the papacy to Constans II’s monothelite doctrines and a bitter conflict between the sees of Rome and Ravenna over the same emperor’s grant of ecclesiastical autonomy (autokephalia) to the latter in 666. In two letters addressed to his successor, Pope Agatho (678–81) bemoaned the dislocation caused by the ‘gentiles’ and complained that lack of food forced the clergy to work the land.
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.
The capture of volatile radioactive iodine-129 is an important process for nuclear fission. Biphenyl-bridged wrinkled mesoporous silica shows similar performance for iodine sequestration to commercial Ag-mordenite and avoids the use of expensive silver. The biphenyl-wrinkled mesoporous silica nanoparticles function as a scaffold for biphenyl groups and also as a fluorescent indicator for the loading of iodine. The nanoparticles have a surface area of 973 m2/g and the biphenyl molecules form an electron charge-transfer complex with iodine. Iodine was loaded into the biphenyl-bridged wrinkled mesoporous silica (BWMS) at 19 ± 0.2 % loading by mass.
Rapidly advancing technology often pulls the regulatory field along as it evolves to incorporate new concepts, better tools, and more finely honed equipment. When the area impacted by the technological advancement is regulated by the Food and Drug Administration (FDA), a gap develops between the technology and the guidelines that govern its application. Subsequently, there are challenges in determining appropriate regulatory pathways for evolving products at the initial research and developmental stages. Myriad factors necessitate several rounds of iterative review and the involvement of multiple divisions within the FDA. To better understand the regulatory science issues roiling around the area of additive manufacturing of medical products, a group of experts, led by a Clinical and Translational Science Award working group, convened the Regulatory Science to Advance Precision Medicine at the Fall Forum to discuss some of the current regulatory science roadblocks.
Documenting leads and lags in terrestrial records of past climate change is critical to understanding the behavior of Earth’s natural climate system and making reliable predictions of future climate conditions. However, uncertainties of several hundred years in age models make it difficult to distinguish synchronicity and feedbacks in paleo archives. In lakes this is often due to the lack of terrestrial macrofossils in climate-sensitive locations, such as high alpine or dryland settings. The potential of radiocarbon (14C) dating of pollen has long been recognized, but the difficulty of cleanly separating pollen from other kinds of organic carbon has limited its usefulness. Here we report 14C ages on pollen separated by flow cytometry, from a set of closely spaced samples from Mono Lake, California. The accuracy of the pollen ages is tested using well-dated bracketing tephras, the South Mono and North Mono-Inyo tephras. In spite of the purity of the sorted samples, the pollen dates are older than the bounding tephras by ~400 yr, similar to some other pollen-dating studies. While improvements in sample preparation protocols are planned, understanding the geological processes involved in the production, preservation, and deposition of pollen at each site will be critical to developing robust high-resolution age models.
Both childhood maltreatment and insecure attachment are known to be associated with depression in adulthood. The extent insecure attachment increases the risk of adult clinical depression over that of parental maltreatment among women in the general population is explored, using those at high risk because of their selection for parental maltreatment together with an unselected sample.
Semi-structured interviews and investigator-based measures are employed.
Insecure attachment is highly associated with parental maltreatment with both contributing to the risk of depression, with attachment making a substantial independent contribution. Risk of depression did not vary by type of insecure attachment, but the core pathways of the dismissive and enmeshed involved the whole life course in terms of greater experience of a mother's physical abuse and their own anger as an adult, with both related to adult depression being more often provoked by a severely threatening event involving humiliation rather than loss. By contrast, depression of the insecure fearful and withdrawn was more closely associated with both current low self-esteem and an inadequately supportive core relationship. In terms of depression taking a chronic course, insecure attachment was again a key risk factor, but with this now closely linked with the early experience of a chaotic life style but with this involving only a modest number of women.
Both insecure attachment and parental maltreatment contribute to an increased risk of depression with complex effects involving types of insecure attachment.
The objective of this study was to prospectively validate the “Brief Developmental Assessment”, which is a new early recognition tool for neurodevelopmental abnormalities in children with heart disease that was developed for use by cardiac teams.
This was a prospective validation study among a representative sample of 960 pre-school children with heart disease from three United Kingdom tertiary cardiac centres who were analysed grouped into five separate age bands.
The “Brief Developmental Assessment” was successfully validated in the older four age bands, but not in the youngest representing infants under the age of 4 months, as pre-set validation thresholds were met – lower 95% confidence limit for the correlation coefficient above 0.75 – in terms of agreement of scores between two raters and with an external measure the “Mullen Scales of Early Learning”. On the basis of American Association of Pediatrics Guidelines, which state that the sensitivity and specificity of a developmental screening tool should fall between 70 and 80%, “Brief Developmental Assessment” outcome of Red meets this threshold for detection of Mullen scores >2 standard deviations below the mean.
The “Brief Developmental Assessment” may be used to improve the quality of assessment of children with heart disease. This will require a training package for users and a guide to action for abnormal results. Further research is needed to determine how best to deploy the “Brief Developmental Assessment” at different time points in children with heart disease and to determine the management strategy in infants younger than 4 months old.
Outcome measures for mental health services need to adopt a service-user recovery focus.
To develop and validate a 10- and 20-item self-report recovery-focused quality of life outcome measure named Recovering Quality of Life (ReQoL).
Qualitative methods for item development and initial testing, and quantitative methods for item reduction and scale construction were used. Data from >6500 service users were factor analysed and item response theory models employed to inform item selection. The measures were tested for reliability, validity and responsiveness.
ReQoL-10 and ReQoL-20 contain positively and negatively worded items covering seven themes: activity, hope, belonging and relationships, self-perception, well-being, autonomy, and physical health. Both versions achieved acceptable internal consistency, test–retest reliability (>0.85), known-group differences, convergence with related measures, and were responsive over time (standardised response mean (SRM) > 0.4). They performed marginally better than the Short Warwick-Edinburgh Mental Well-being Scale and markedly better than the EQ-5D.
Both versions are appropriate for measuring service-user recovery-focused quality of life outcomes.
Declaration of interest
M.B. and J.Co. were members of the research group that developed the Clinical Outcomes in Routine Evaluation (CORE) outcome measures.
The re-emergence of debates on the decolonisation of knowledge has revived interest in the National Question, which began over a century ago and remains unresolved. Tensions that were suppressed and hidden in the past are now being openly debated. Despite this, the goal of one united nation living prosperously under a constitutional democracy remains elusive. This edited volume examines the way in which various strands of left thought have addressed the National Question, especially during the apartheid years, and goes on to discuss its relevance for South Africa today and in the future. Instead of imposing a particular understanding of the National Question, the editors identified a number of political traditions and allowed contributors the freedom to define the question as they believed appropriate – in other words, to explain what they thought was the Unresolved National Question. This has resulted in a rich tapestry of interweaving perceptions. The volume is structured in two parts. The first examines four foundational traditions: Marxism-Leninism (the Colonialism of a Special Type thesis); the Congress tradition; the Trotskyist tradition; and Africanism. The second part explores the various shifts in the debate from the 1960s onwards, and includes chapters on Afrikaner nationalism, ethnic issues, black consciousness, feminism, workerism and constitutionalism. The editors hope that by revisiting the debates not popularly known among the scholarly mainstream, this volume will become a catalyst for an enriched debate on our identity and our future.
Capital accumulation in South Africa started off as a process of ‘accumulation by dispossession’ (Harvey, 2010: 48–49). War, violence, predation, thievery, criminality, fraud … these were the means by which the indigenous people were dispossessed of their communal lands, and by which the basis to wealth in this country passed into the hands of the capitalists.
South Africa was incorporated into the world economy as an enclave – as a colonial economy established by imperialist class interests primarily for the exploitation of its raw material resources (Mhone, 2001). Our economy was typically characterised by a capital-intensive sector co-existing with a capital-starved traditional economy. Although often described as ‘dual’, they are by no means ‘separate’. The capitalist sector, particularly the gold mining industry, was critically dependent on the traditional economy for the ongoing supply of ‘ultra-cheap, ultra-exploitable’ supplies of labour (Johnstone, 1976). By providing a subsistence base, the traditional economy in effect lowered the minimal acceptable wage threshold of labour (Wallerstein, 2003), thereby ensuring the very existence and sustainability of the capitalist system in this country.
Herein lies the root of our so-called National Question for, historically, class rule in South Africa has been about institutionalising ‘systems of duality’ in our society in order to extend and maintain the conditions of exploitation. It is against this background that divide and rule as a fundamental mechanism of class rule needs to be understood.
Capitalism's interests were served by dividing the nation, by perpetuating a core-periphery duality in society and the economy.
Historically, this has created the conditions of struggle in South Africa. It explains why opposition that was predicated on the principle of ‘one single South African nation’ has had revolutionary implications – why a call for a non-racial democracy was a fundamental threat to the very basis of capital accumulation.
Habitat preferences and response to habitat conversion remain under-studied for many groups in the tropics, limiting our understanding of how environmental and anthropogenic factors may interact to shape patterns of diversity. To help fill this knowledge gap, we surveyed nocturnal birds such as owls, nightjars and potoos through auditory transect surveys in 22 forest fragments (2.7 to 33.6 ha) in north-west Ecuador. We assessed the relative effect of habitat characteristics (e.g. canopy height and openness, and density of large trees) and fragment attributes (e.g. area, altitude and proportion of surrounding forest cover) on species richness and community composition. Based on our previous work, we predicted that nocturnal bird richness would be highest in relatively larger fragments with more surrounding forest cover. We recorded 11 total species with an average ± SD of 3.4 ± 1.4 (range = 2–7) species per fragment, with higher richness in fragments that were larger, at lower altitudes, and characterized by more open canopies. Nocturnal bird community similarity was not significantly correlated with any measured environmental variable. These results indicate that both landscape (e.g. altitude) and fragment-specific (e.g. size, forest structure) attributes are likely to interact to shape patterns of diversity among this poorly known but ecologically important guild in fragmented tropical landscapes.