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Many recorded roll calls in Congress each year are votes on bills that have no chance of becoming law, or are purely symbolic, or are procedural without policy content. Yet models of voting and measurement models of member preferences make assumptions that vote choices are largely about utility derived from policies. We consider the possibility that votes plausibly connected to policy and votes not plausibly connected to policy may have different data-generating processes and rely on different utility functions. Substantively, similarity across different contexts for policy change implies an importance of messaging over policy. Methodologically, similarity across these contexts is necessary to avoid biasing estimates of member preferences. We find that members’ voting patterns are highly stable across contexts in which policy change is credible and not credible. This indicates that existing measures of ideal points are likely not dramatically biased by the inclusion of policy-irrelevant votes.
South Africa has embarked on major health policy reform to deliver universal health coverage through the establishment of National Health Insurance (NHI). The aim is to improve access, remove financial barriers to care, and enhance care quality. Health technology assessment (HTA) is explicitly identified in the proposed NHI legislation and will have a prominent role in informing decisions about adoption and access to health interventions and technologies. The specific arrangements and approach to HTA in support of this legislation are yet to be determined. Although there is currently no formal national HTA institution in South Africa, there are several processes in both the public and private healthcare sectors that use elements of HTA to varying extents to inform access and resource allocation decisions. Institutions performing HTAs or related activities in South Africa include the National and Provincial Departments of Health, National Treasury, National Health Laboratory Service, Council for Medical Schemes, medical scheme administrators, managed care organizations, academic or research institutions, clinical societies and associations, pharmaceutical and devices companies, private consultancies, and private sector hospital groups. Existing fragmented HTA processes should coordinate and conform to a standardized, fit-for-purpose process and structure that can usefully inform priority setting under NHI and for other decision makers. This transformation will require comprehensive and inclusive planning with dedicated funding and regulation, and provision of strong oversight mechanisms and leadership.
HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities.
A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March–May 2016 and followed up March–May 2017.
HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records.
In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9–53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0–28.6 n = 16) was observed.
HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.
Beryl from Xuebaoding, Sichuan Province, western China is known for its unusual tabular habit and W–Sn–Be paragenesis in a greisen-type deposit. The crystals are typically colourless transparent to pale blue, often with screw dislocations of hexagonal symmetry on the (0001) crystal faces. Combining electron microprobe analyses and laser ablation inductively coupled plasma mass spectrometry with single-crystal X-ray diffraction (XRD), correlated with Raman and micro-infrared (IR) spectroscopy and imaging, the crystal chemical characteristics are determined. The contents of Na+ (0.24–0.38 atoms per formula unit (apfu)) and Li+ up to 0.38 apfu are at the high end compared to beryl from other localities worldwide. Li+ substitution for Be2+ on the tetrahedral (T2) site is predominantly charge balanced by Na+ on the smaller channel (C2) site, with Na+ ranging from 91.5% to 99.7% (apfu) of the sum of all other alkali elements. Cs+ and minor Rb+ and K+ primarily charge balance the minor M2+ substitution for Al3+ at the A site; all iron at the A site is suggested to be trivalent. The a axis ranges from 9.2161(2) to 9.2171(4) Å, with unit-cell volume from 678.03(3) to 678.48(7) Å3. The c/a ratio of 1.0002–1.0005 is characteristic for T2-type beryl with unit-cell parameters controlled primarily by Be2+ substitution. Transmission micro-IR vibrational spectroscopy and imaging identifies coordination of one or two water molecules to Na+ (type IIs and type IId, respectively) as well as alkali free water (type I). Based on IR absorption cross section and XRD a C1 site water content of 0.4–0.5 apfu is derived, i.e. close to 50% site occupancy. Secondary crystal phases with a decrease in Fe and Mg, yet increase in Na, suggest early crystallisation of aquamarine, with goshenite being late. With similar crystal chemistry to beryl of columnar habit from other localities worldwide, the tabular habit of Xuebaoding beryl seems to be unrelated to chemical composition and alkali content.
Motivational factors are generally regarded as an important ingredient for change in therapy. However, there is currently a lack of available instruments that can measure clients’ readiness for change in therapy.
The objective of this paper was to create an instrument, the Readiness for Therapy Questionnaire (RTQ), which could measure clients’ readiness for change.
The RTQ was created by researchers following analysis of themes drawn from a review of the literature and interviews with patients at the end of therapy. This included both people who completed therapy and those who dropped out. As part of the standard assessment process, the RTQ was administered to 349 participants (69.6% female and 30.4% male; mean age 37.1 years; 90.5% Caucasian) who were patients at a psychological therapy service for common mental health difficulties.
An initial 12-item scale was reduced to 6 items. This scale significantly correlated with post-therapy PHQ-9 and GAD-7 scores and changes in these scores across therapy. After controlling for baseline scores and demographic variables, a logistic regression showed that scores on this 6-item measure pre-therapy significantly predicted three outcome variables: completing therapy, being recovered on both PHQ-9 and GAD-7 post-therapy, and having a reliable change in both the PHQ-9 and GAD-7 post-therapy. However, receiver operating characteristic (ROC) curve analysis showed the measure had poor sensitivity and specificity. Symptom severity did not have a significant impact on motivation to change.
The RTQ is potentially a valid measure with useful clinical applications in treatment of common mental health difficulties.
Agronomic crops engineered with resistance to 2,4-D or dicamba have been commercialized and widely adopted throughout the United States. Because of this, increased use of these herbicides in time and space has increased damage to sensitive crops. From 2014 to 2016, cucumber and cantaloupe studies were conducted in Tifton, GA, to demonstrate how auxinic herbicides (namely, 2,4-D or dicamba), herbicide rate (1/75 or 1/250 field use), and application timing (26, 16, and 7 d before harvest [DBH] of cucumber; 54, 31, and 18 DBH of cantaloupe) influenced crop injury, growth, yield, and herbicide residue accumulation in marketable fruit. Greater visual injury, reductions in vine growth, and yield loss were observed at higher rates when herbicides were applied during early-season vegetative growth compared with late-season with fruit development. Dicamba was more injurious in cucumber, whereas cantaloupe responded similarly to both herbicides. For cucumber, total fruit number and relative weights were reduced (16% to 19%) when either herbicide was applied at the 1/75 rate 26 DBH. Cantaloupe fruit weight was also reduced 21% and 10% when either herbicide was applied at the 1/75 rate 54 or 31 DBH, respectively. Residue analysis noted applications made closer to harvest were more likely to be detectable in fruit than earlier applications. In cucumber, dicamba was detected at both rates when applied 7 DBH, whereas in cantaloupe, it was detected at both rates when applied 18 or 31 DBH in 2016 and at the 1/75 rate applied 18 or 31 DBH in 2014. Detectable amounts of 2,4-D were not observed in cucumber but were detected in cantaloupe when applied at either rate 18 or 31 DBH. Although early-season injury will more likely reduce cucumber or cantaloupe yields, the quantity of herbicide residue detected will be most influenced by the time interval between the off-target incident and sampling.
The representation of nature is central to Wagner’s Ring cycle on a number of levels. The Nordic-mythic sources and setting, the role of original or partially re-invented nature deities (Erda, Donner, and Froh, and the three Rhinemaidens) or semi-divine beings linked to the natural world (Valkyries, Norns) inspired a range of sophisticated Romantic musical nature “painting” throughout the score, including some of the best-known passages. Classical-Romantic traditions of pastoral or other imitative nature topics in music of the Classical and Romantic eras play an important role in the development of the network of leitmotifs in the Ring cycle. Readings of the Ring as an allegorical critique of modern industrial capitalism connect the traditional mythography of a lost golden age with a potential parable of environmental degradation driven by the loveless, reckless profit motive of modern capitalism. Alberich’s forging of the Ring from the Rhinegold and Wotan’s violation of the World Ash Tree to create the symbol of his divine legal authority (his spear) project parallel symbols of the transgression of a natural order. Mythographic vs. modern environmental readings of the apocalyptic conclusion of the cycle are also discussed.
This chapter by Thomas Grey presents a focused yet far-reaching account of the significance of dance to Richard Wagner. First, it explores how Wagner theorized the roles of dance, music and text in his ‘total artwork’; then it considers historical practice – examples of the actual dances (and also what the author calls the ‘sublimated choreography’) in several Wagnerian music dramas, especially Tannhäuser, with its infamous Venusberg ‘Bacchanal’. Wagner’s feelings towards dance were double-edged. On the one hand, the composer acknowledged the importance of movement and gesture in the creation of his ideal artwork. Indeed, as Grey suggests, Wagner sought to play up the two, emphasizing the role of the erotic, sexualized body onstage. On the other hand, Wagner liked to ridicule contemporary ballet. But, to Wagner, ballet’s problematic status did not relate to its explicitly bodily and human aspects. Instead, it was the genre’s association with an institutional context – ballet as produced and consumed at the Paris Opéra – that troubled the composer.
Culturally safe health practitioners are essential for effective service provision to culturally diverse populations, including Indigenous Australians. Therefore, cultural safety education during training as a health care professional is an essential component in helping improve the health of Indigenous Australians. This study examined whether the implementation of an Indigenous cultural safety education workshop increased self-rated cultural safety knowledge and attitudes of allied health students. The study employed a quantitative before-and-after design using pre- and post-surveys to determine the level of attitudinal change in students who attended a day long workshop. The study sample consisted of 1st year (n = 347) and 4th year (n = 149) allied health students at a regional Australian university over the years 2007–2011. Whilst the results of this current study are varied in terms of achieving positive change across all of the taught items of knowledge and attitude, they provide some evidence around the value of this type of curriculum intervention in helping develop culturally safe practitioners. An important finding was around the student's becoming self-aware about their own values and cultural identity, combined with acknowledging the importance of this cultural identity to interactions with clients. This form of ‘cultural humility’ appears to be an important step to becoming a culturally safe practitioner. These types of interventions would be enhanced through embedding and scaffolding throughout the curricula.
Research on presidential power delineates between a modern era of relative autonomy and an earlier period of congressional dominance. What drove this change? Unlike prior arguments about presidential entrepreneurship and the rise of the United States as a global power, we attribute the emergence of the modern presidency partially to an institutional change—the adoption of direct election of senators that culminated in the 17th Amendment. With direct election, senators were selected by individual voters rather than state legislators. These senators answered to a new principal—the general public—that was (in the aggregate) less informed and less interested in foreign policy. As a result, senators had less incentive to constrain presidential foreign policy preferences. We find evidence for this shift in the relationship between the piecemeal adoption of direct election and senate votes to delegate foreign policy authority to the executive. The implication is that the direct election of senators played an underappreciated role in the emergence of the modern presidency.
Trend analyses based on dietary records suggest decreases in the intakes of total sugar (TS), added and free sugar since 2005 among children and adolescents in Germany. In terms of age trends, TS intake decreased with increasing age. However, self-reported sugar intake in epidemiological studies is criticised, as it may be prone to bias due to selective underreporting. Furthermore, adolescents are more susceptible to underreporting than children. We thus analysed time and age trends in urinary fructose excretion (FE), sucrose excretion (SE) and the sum of both (FE + SE) as biomarkers for sugar intake among 8·5–16·5-year-old adolescents. Urinary sugar excretion was measured by UPLC-MS/MS in 997 24-h urine samples collected from 239 boys and 253 girls participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study cohort between 1990 and 2016. Time and age trends of log-transformed FE, SE and FE + SE were analysed using polynomial mixed-effects regression models. Between 1990 and 2016, FE as well as FE + SE decreased (linear time trend: P = 0·0272 and P < 0·0001, respectively). A minor increase in excretion during adolescence was confined to FE (linear age trend: P = 0·0017). The present 24-h excretion measurements support a previously reported dietary record-based decline in sugar intake since 2005. However, the previously seen dietary record-based decrease in TS from childhood to late adolescence was not confirmed by our biomarker analysis, suggesting a constant sugar intake for the period of adolescence.
Methionine, an essential sulphur-containing amino acid (SAA), plays an integral role in many metabolic processes. Evidence for the methionine requirements of adult dogs is limited, and we employed the indicator amino acid oxidation (IAAO) method to estimate dietary methionine requirements in Labrador retrievers (n 21). Using semi-purified diets, the mean requirement was 0·55 (95 % CI 0·41, 0·71) g/4184 kJ. In a subsequent parallel design study, three groups of adult Labrador retrievers (n 52) were fed semi-purified diets with 0·55 g/4184 kJ (test diet 1), 0·71 g/4184 kJ (test diet 2) or 1·37 g/4184 kJ (control diet) of methionine for 32 weeks to assess the long-term consequences of feeding. The total SAA content (2·68 g/4184 kJ) was maintained through dietary supplementation of cystine. Plasma methionine did not decrease in test group and increased significantly on test diet 1 in weeks 8 and 16 compared with control. Reducing dietary methionine did not have a significant effect on whole blood, plasma or urinary taurine or plasma N-terminal pro B-type natriuretic peptide. Significant effects in both test diets were observed for cholesterol, betaine and dimethylglycine. In conclusion, feeding methionine at the IAAO-estimated mean was sufficient to maintain plasma methionine over 32 weeks when total SAA was maintained. However, choline oxidation may have increased to support plasma methionine and have additional consequences for lipid metabolism. While the IAAO can be employed to assess essential amino acid requirements, such as methionine in the dog using semi-purified diets, further work is required to establish safe levels for commercial diet formats.
Unexpected disasters, such as earthquakes or fires, require preparation to address knowledge gaps that may negatively affect vulnerable patients. Training programs can promote natural disaster readiness to respond and evacuate patients safely, but also require evidence-based information to guide learning objectives.
There is limited evidence on what skills and bedside equipment are most important to include in disaster training and evacuation programs for critically ill infants.
An expert panel was used to create a 13-item mastery checklist of skills for bedside registered nurses (RNs) required to successfully evacuate a critically ill infant. Expert nurses were surveyed, and the Angoff method was used to determine which of the mastery checklist skills a newly graduated nurse (ie, the “minimally competent” nurse) should be able to do. Participants then rated the importance of 26 commonly available pieces of bedside equipment for use in evacuating a hemodynamically unstable, intubated infant during a disaster.
Twenty-three emergency department (ED) and neonatal intensive care unit (NICU) charge RNs responded to the survey with a mean of 19 (SD = 9) years of experience and 30% reporting personal experience with evacuating patients. The skills list scores showed an emphasis on the newly graduated nurse having more complete mastery of skills surrounding thermoregulation, documentation, infection control, respiratory support, and monitoring. Skills for communication, decision making, and anticipating future needs were assessed as less likely for a new nurse to have mastered. On a scale of one (not important) to seven (critically important), the perceived necessity of equipment ranged from a low of 1.6 (breast pump) to a high of 6.9 (face mask). The individual intraclass correlation coefficient (ICC) of 0.55 showed moderate reliability between raters and the average team ICC of 0.97 showed excellent agreement as a group.
Experts rated the ability to manage physiological issues, such as thermoregulation and respiratory support, as skills that every nurse should master. Disaster preparedness activities for nurses in training may benefit from checklists of essential equipment and skills to ensure all nurses can independently manage patients’ physiologic needs when they enter the workforce. Advanced nursing training should include education on decision making, communication during emergencies, and anticipation of future issues to ensure that charge and resource nurses can support bedside nurses during evacuation events.
Deciduous dipterocarp forests throughout Asia provide crucial habitat for several globally threatened species. During the dry season water availability in these forests is primarily limited to perennial rivers and waterholes. Such water sources form an essential part of these dry forests and are used by multiple species, including large mammals and birds, but little is known regarding how waterhole characteristics affect wildlife use. We investigated waterhole utilization by six globally threatened dry forest specialists: banteng Bos javanicus, Eld's deer Rucervus eldii, giant ibis Thaumatibis gigantea, green peafowl Pavo muticus, lesser adjutant Leptoptilos javanicus and Asian woolly-necked stork Ciconia episcopus. We camera-trapped 54 waterholes in Srepok Wildlife Sanctuary, eastern Cambodia, during the dry season of December 2015–June 2016. We measured nine waterhole and landscape characteristics, including indicators of human disturbance. Waterhole depth (measured every 2 weeks) and the area of water at the start of the dry season were the main environmental factors influencing waterhole use. Additionally, waterholes further from villages were more frequently used than those nearer. Our study reaffirmed the importance of waterholes in supporting globally threatened species, especially large grazers, which are critical for maintaining these dry forest ecosystems. The results also suggested that artificially enlarging and deepening selected waterholes, particularly those further from human disturbance, could enhance available habitat for a range of species, including grazers. However, this would need to be conducted in coordination with patrolling activities to ensure waterholes are not targets for illegal hunting, which is a problem throughout South-east Asian protected areas.
To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).
Descriptive retrospective cohort with nested case-control study.
Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.
Children≤18 years ventilated for≥1 calendar day.
We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.
Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0–43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.
Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
Introduction: Online medical education resources are widely used in emergency medicine (EM), but strategies to assess quality remain elusive. We previously derived the Medical Education Translational Resources: Impact and Quality (METRIQ) 8 instrument to evaluate quality in medical education blog posts. Methods: As part of a subsequent validation study (The METRIQ Blog Study), a mixed-methods usability analysis was performed to obtain user feedback on the quality assessment instrument in order to improve its clarity and reliability. Participants in the METRIQ Study were first asked to rate five blog posts using the METRIQ-8 Score. They then evaluated the METRIQ-8 instruments ease of use and likelihood of being recommended to others using a 7-point Likert scale and free text comments. Participants were also asked to flag and comment on items within the score that they felt were unclear. Global usability ratings were summarized using median scores or percent rated unclear. We used ANOVA to test associations between ease of use and demographic factors. A thematic analysis was performed on the comments. Results: 309 EM medical students, residents, and attendings completed the survey. Global ratings were generally very favorable (median 2 [IQR 2-3], with 7 being the lowest score) for ease of use and likelihood of recommendation, and did not vary by participants country of origin, frequency of blog use, or learner level. Participants stated that the score was structured, systematic, and straightforward. They found it useful for junior learners and for guiding blog creation. Four questions in the score (questions 2, 4, 5, and 7) were identified by 10% of subjects to be unclear. Thematic analysis of comments identified suggested four main themes for improving the score: adding clearer definitions with marking rubrics; shortening the 7-point scale; adding items evaluating blog post presentation and utility; and, rephrasing the wording of certain questions for clarity. Conclusion: A mixed methods usability analysis of the METRIQ-8 instrument for assessing blog quality was globally well received by EM medical students, residents, and attendings. Qualitative analyses revealed multiple areas to improve the instruments clarity and usability. The METRIQ score is a promising instrument for evaluating the quality of blogs; further development and testing is needed to improve its utility.
The commercial release of crops with engineered resistance to 2,4-D and dicamba will alter the spatial and temporal use of these herbicides. This, in turn, has elicited concerns about off-target injury to sensitive crops. In 2014 and 2015, studies were conducted in Tifton, GA, to describe how herbicide (2,4-D and dicamba), herbicide rate (1/75 and 1/250 field use), and application timing (20, 40, and 60 DAP) influence watermelon injury, vine development, yield, and the accumulation of herbicide residues in marketable fruit. In general, greater visual injury and reductions in vine growth, relative to the non-treated check, were observed when herbicide applications were made before watermelon plants had begun to flower. Although the main effects of herbicide and rate were less influential than the timing of applications with respect to plant development, the 1/75 rates were more injurious than the 1/250 rates; dicamba was more injurious than 2,4-D. In 2014, the 1/75 and 1/250 rates of each herbicide reduced marketable fruit numbers 13 to 20%, but only for the 20 DAP application. The 1/75 rate of each herbicide when applied at either 20 or 40 DAP reduced the number of fruit harvested per plot in 2015. Dicamba residues were detected in marketable fruit when the 1/75 rate in 2014 and 2015 and the 1/250 rate in 2015 was applied to plants at 40 or 60 DAP. Residues of 2,4-D were detected in 2015 when the 1/75 and 1/250 rates were applied at 60 DAP. Across both years, the maximum level of residue detected was 0.030 ppm. While early season injury may reduce watermelon yields, herbicide residue detection is more likely in marketable fruit when an off-target contact incident occurs closer to harvest.