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The Paris peace settlements following the First World War remain amongst the most controversial treaties in history. Bringing together leading international historians, this volume assesses the extent to which a new international order, combining old and new political forms, emerged from the peace negotiations and settlements after 1918. Taking account of new historiographical perspectives and methodological approaches to the study of peacemaking after the First World War, it views the peace negotiations and settlements after 1918 as a site of remarkable innovations in the practice of international politics. The contributors address how a wide range of actors set out new ways of thinking about international order, established innovative institutions, and revolutionised the conduct of international relations. They illustrate the ways in which these innovations were merged with existing practices, institutions, and concepts to shape the international order that emerged out of the Paris Peace Conference of 1919.
This chapter strikingly demonstrates the importance of medieval literary representations of the environment for more contemporary concerns. Amy Mulligan analyzes the medieval figure of the Sovereignty Goddess in literature written in the Irish language and shows its centrality in the environmental education of male rulers. Further relevance of the medieval for the contemporary ecological regime is revealed in treating medieval literature as one that provides a systematic understanding, often surprisingly scientific, such as Gerald of Wales’s accounts, “of Ireland’s birds and fishes” that are “invaluable in describing species, some of which are now extinct” and can act as guide to understand the nature of “ecological imperialism” in Ireland. Mulligan concludes that “All these medieval practitioners of Irish nature-writing develop a mode of thinking about the environment as a creative and generative space, one which is highly anthropocentric but which, through adoration, wonder, even recognition of something divine in the trees, soil, water, and animals” makes continued human habitability on this planet a historical possibility.
To overcome grass supply shortages on the main grazing block, some pasture-based dairy farmers are using zero-grazing (also known as ‘cut and carry’), whereby cows are periodically housed and fed fresh grass harvested from external land blocks. To determine the effect of zero-grazing on cow performance, two early-lactation experiments were conducted with autumn and spring-calving dairy cows. Cows were assigned to one of two treatments in a randomized complete block design. The two treatments were zero-grazing (ZG) and grazing (G). The ZG group were housed and fed zero-grazed grass, while the G group grazed outdoors at pasture. Both treatments were fed perennial ryegrass (Lolium perenne L.) from the same paddock. In experiment 1, 24 Holstein Friesian cows (n = 12) were studied over a 35-day experimental period in autumn and offered fresh grass, grass silage, ground maize and concentrates. In experiment 2, 30 Holstein Friesian cows (n = 15) were studied over a 42-day experimental period and offered fresh grass and concentrates. Average dry matter intake and milk yield was similar for ZG and G in both experiments. Likewise, ZG did not have an effect on milk composition, body condition or locomotion. Zero-grazing had no effect on total nitrogen excretion or nitrogen utilization efficiency in either experiment, or on rumen pH and ammonia concentration in experiment 1. While zero-grazing may enable farmers to supply fresh grass to early-lactation cows in spring and autumn, results from this study suggest that there are no additional benefits to cow performance in comparison to well-managed grazed grass.
This research adds to scarce literature regarding adolescent experiences of traumatic brain injury (TBI). Retrospective accounts of young adults who had sustained a TBI in adolescence were analysed to explore the perceived impact this had on their lives and forming identities during this important developmental stage.
Thirteen adults (aged 20–25 years; mean 23 years) who sustained a mild or moderate TBI during adolescence (i.e. aged 13–17 years at injury), approximately 7.7 years (range = 6.7–8.0 years) prior, participated in the research. Semi-structured individual interviews, analysed using thematic analysis, explored participants’ experiences following their TBIs.
Thematic analysis of interview data produced two categories of themes: (1) Impacts on Important Areas of Life, which included: schoolwork suffered, career opportunities became limited, struggling with work and missing out socially; and (2) Impacts on Identity: with themes including feeling ‘stupid’, feeling self-conscious, loss of social identity and being dependent.
TBI sustained during adolescence can have broad impacts on important areas of life and on developing identity.
Background: Prolonged antibiotic use has been attributed to an increased incidence of adverse drug events (ADEs). Cessation of unnecessary antibiotics would decrease length of treatment and may help prevent these adverse events. We evaluated whether an antibiotic stewardship intervention aimed at stopping unnecessary antibiotic usage would both shorten the duration of treatment and reduce ADEs. Methods: At NorthShore University HealthSystem, a 4-hospital, 832-bed system, we identified patients who were started on empiric antibiotics during a hospital admission between May 2, 2016, and June 30, 2018. Within 24 hours of antibiotic initiation, an infectious disease (ID) physician reviewed each patient chart. If the patient was unlikely to have a symptomatic bacterial infection, the ID physician left a note in the electronic medical record (EMR) recommending antibiotic cessation. Two physician reviewers retrospectively reviewed whether the treatment team accepted these recommendations and assessed potential ADEs for 30 days after the recommendation through inpatient and outpatient notes in the EMR. These ADEs were defined using previously published criteria. If the 2 reviewers disagreed on the presence of an ADE, an ID physician acted as the tie breaker. We compared the number of antibiotic days and the number of ADEs between cases in which the recommendations were followed and cases in which they were not. Results: We reviewed 168 cases: 78 (46.43%) followed recommendations and 90 (53.57%) did not. There were no significant differences in baseline patient characteristics between the 2 groups. There was a significant difference in total ADEs between the 2 groups: in 6 cases (7.69%) the recommendations were followed, and 21 (23.33%) they were not followed (P = .011). There was also a significant difference in antibiotic days between cases in which recommendations were followed (1.40 days) versus those in which they were not followed (1.99 days) (p < 0.001). Conclusions: Antibiotic-associated adverse events can cause harm to patients and increase healthcare costs, particularly when used for patients who are unlikely to have a bacterial infection. An antibiotic stewardship program to identify patients in an EMR who are unlikely to benefit from antibiotic use can decrease the length of total antibiotic usage and help prevent adverse events.
The “shutdown” economy of April 2020 is compared to a normally functioning economy both in terms of market and nonmarket activities. Three novel methods and data indicate that a full shutdown of “nonessential” activities puts market production about 25 % below normal in the short run. At an annual rate, a full shutdown costs $9 trillion, or about $18,000 per household per quarter. Employment already fell 24 million by early April 2020. These costs indicate, among other things, the value of innovation in both health and general business sectors that can accelerate the time when, and the degree to which, normal activity resumes.
Studies of prosumer decision making in the smart grid have focused on a single decision within the framework of expected utility theory (EUT) and behavioral theories such as Prospect Theory. This chapter studies prosumer decision making in a more natural market situation in which a prosumer has to decide whether to make a sale of solar energy units generated at her home every day or hold (store) the energy units in anticipation of a future sale at a better price. Specifically, it proposes a new behavioral model that extends EUT to take into account bounded horizons (in terms of the number of days) that prosumers implicitly impose on their decision making in arriving at “hold” or “sell” decisions of energy units. The new behavioral model assumes that humans make decisions that will affect their lives within a bounded horizon regardless of how far into the future their units may be sold. Modeling the utility of the prosumer using parameters such as the offered price on a day, the available energy units on a day, and the probabilities of the forecast prices, both traditional EUT and the proposed behavioral model with bounded horizons are ﬁt to prosumer data.
This research communication addressed the hypothesis that late lactation cows offered an oat-grain-based supplement or a high level of α-TOC supplementation at pasture would have improved milk composition and processability. Over a grazing period of 49 d, 48 Holstein Friesian dairy cows were randomly assigned to one of four dietary treatments. The dietary treatments were: control, pasture only (CTRL), pasture + 2.65 kg DM barley-based concentrate + 350 IU α-TOC/kg (BARLO), pasture + 2.65 kg DM oat-based concentrate + 350 IU α-TOC/kg (OATLO) and pasture + 2.65 kg DM oat-based concentrate + 1050 IU α-TOC/kg (OATHI). Within this randomised complete block design experiment cows were blocked on days in milk (DIM) and balanced for parity, milk yield and composition. Rennet coagulation time (RCT) was reduced in milk from cows offered OATHI compared to CTRL cows and OATLO. Concentration of conjugated linoleic acid (CLA) was increased by OATHI compared to OATLO and in OATLO compared to CTRL. Supplementation with OATHI reduced individual saturated fatty acids (SFAs) in milk compared to OATLO. In conclusion, supplementing grazing dairy cows with an oat-based supplement improved total milk CLA concentration compared to pasture only. Offering a high level of α-TOC (2931 IU/d) to dairy cows reduced RCT, individual SFA and increased total CLA concentration of milk compared to a lower α-TOC level (738 IU α-TOC/d).
There has been a long history of conflicts, studies, and debate over how to both protect rivers and develop them sustainably. With a pause in new developments caused by the global pandemic, anticipated further implementation of the Paris Agreement and high-level global climate and biodiversity meetings in 2021, now is an opportune moment to consider the current trajectory of development and policy options for reconciling dams with freshwater system health.
We calculate potential loss of free-flowing rivers (FFRs) if proposed hydropower projects are built globally. Over 260,000 km of rivers, including Amazon, Congo, Irrawaddy, and Salween mainstem rivers, would lose free-flowing status if all dams were built. We propose a set of tested and proven solutions to navigate trade-offs associated with river conservation and dam development. These solution pathways are framed within the mitigation hierarchy and include (1) avoidance through either formal river protection or through exploration of alternative development options; (2) minimization of impacts through strategic or system-scale planning or re-regulation of downstream flows; (3) restoration of rivers through dam removal; and (4) mitigation of dam impacts through biodiversity offsets that include restoration and protection of FFRs. A series of examples illustrate how avoiding or reducing impacts on rivers is possible – particularly when implemented at a system scale – and can be achieved while maintaining or expanding benefits for climate resilience, water, food, and energy security.
Social media summary
Policy solutions and development pathways exist to navigate trade-offs to meet climate resilience, water, food, and energy security goals while safeguarding FFRs.
The standard response to concerns about “black box” algorithms is to make those algorithms transparent or explainable. Such approaches, however, involve significant limitations, especially in professional contexts such as medicine, law, or financial advice. Instead, systems should be designed to be contestable, meaning that those subject to algorithmic decisions can engage with and challenge them. Both laws and norms can encourage contestability of automated decisions, but systems designers still must take explicit steps to promote effective questioning and challenges.
In this time of Covid-19, life in healthcare has changed immeasurably. It has rapidly been injected with an ‘all hands-on deck’ approach, to facilitate the necessary adaptations required to reduce the spread of the virus and deliver frontline clinical care. Inevitably aspects of these changes have disrupted the delivery of medical education, notably clinical placements have been cancelled and social distancing guidelines prohibit face-to-face teaching. The training of future doctors is an essential part of this effort. Indeed, the emergence of a global health threat has underlined its continued importance. For medical educators and students alike, we have been presented with a challenge. Concurrently, this presents us with an impetus and opportunity for innovation. For some time now, a transformation in medical education has been called for, with an increasing recognition of the need to prepare students for the changing landscape of healthcare systems. This has included a focus on the use of technology-enhanced and self-directed learning. As a team of educators and clinicians in psychiatry, working in the School of Medicine and Medical Sciences (SMMS) in University College Dublin (UCD), we will share how we have responded. We outline the adaptations made to our ‘Psychiatry’ module and consider the influence this may have on its future delivery. These changes were informed by direct student input.
The 40 item Social Communication Questionnaire (SCQ) screens for autism spectrum disorder (ASD) and is quicker to administer than the (two hour) Autism Diagnostic Interview-Revised (ADI-R). A recent study, however, found that two questions on the SCQ were answered “autism positive” in 40% of a normal population children's sample. A modified SCQ (MSCQ) without these questions may be more specific than the SCQ.
To compare the performance of the MSCQ with that of the ADI-R.
42 children were recruited to the study, 22 from Mater CAMHS and 20 from St Paul's Hospital and Special School. 20 were diagnosed with autism, 10 with ASD, and 12 with other clinical diagnoses. The MSCQ was sent out as a postal questionnaire to be completed before attending for ADI-R interview. To assess the diagnostic validity of the MSCQ correlations between the MSCQ and ADI-R were calculated. Receiver operating characteristic (ROC) curves were then applied to assess its discriminate ability.
A strong correlation of 0.84 was found between ADI-RTotal and MSCQTotal scores. Using ROC Curves, a cut-off of 14.5 on the MSCQ had a sensitivity of 0.90 and a specificity of 0.82 for identifying ASD from other clinical disorders. A cut-off of 21.5 on the MSCQ had a sensitivity of 0.75 and a specificity of 0.77 for identifying autism from other diagnoses.
These preliminary findings suggest that the MSCQ is a clinically useful and accurate method of assessing for ASD.
The HOME (Caldwell and Bradley) is a well recognised 59 item tool used for assessing the home environment and especially how supportive the home environment is for the child's developmental needs. It is applied in the home and is scored according to rater observations and parent interview answers.
A recent cross sectional study has shown an association between the HOME score and the severity of ADHD symptoms, especially hyperactivity, in children with ADHD. This study will ascertain if the association between symptoms of hyperactivity and the HOME score is present in children with non-ADHD clinical disorders as well as children with ADHD.
Parents of children aged < 10 years attending the Child Guidance Unit, Mater Misericordiae Hospital from 2006 onwards were invited to partake in the study. The HOME was administered to 100 participants and the child's symptoms of inattention and hyperactivity were assessed by administering the Conners’ Parent Rating scale.
A correlational bivariate analysis was performed on parent ratings of inattention and hyperactivity with the total Home score and each subscale. For each set of symptoms, there was a significant and negative correlation with total HOME score: Pearsons's r = -.22, p = .028 for hyperactivity and Pearson's r = -.33, p = .001 for inattention.
Higher scores of hyperactivity and inattention are associated with a lower total HOME score; therefore there is an association between symptoms of hyperactivity and the home environment in children with non-ADHD clinical disorders as well as children with ADHD.
To develop an interview version of the HOME assessment tool and compare the interview version of the HOME with the home visit version.
Families whose child under 10 years of age attending the Mater CAMHS, with first attendance in the past two years were contacted. 100 of the 247 contacted agreed to participate and consented to a family visit. The study had prior ethics approval. A brief interview version of the HOME devised by substituting questions for the observer rated part of the HOME questionnaire was administered prior to the home-visit, where the home-based version of the HOME was performed. Both interviews were then compared and statistically analysed.
The mean score for the home visit HOME was 46.93 ± SD. The comparison of the telephone data with the home visit data suggested that there is a small significant difference between total score for the telephone and the home visit HOME score, with a difference of 0.96 - 3.20 (95% CI), when each of the assessments were scored out of 100. Bell- curves and T-Pairing scores of subscales and individual questions of both interviews suggest similarity.
These results suggest that an interview version of the HOME assessment can be administered in the clinic or by telephone.
This study validated a French language version of an inventory designed to detect symptoms of depression and anxiety [Goldberg et al, 1987] in a sample of elderly French-speaking inpatients at risk for one of these disorders. Latent trait analysis was used to replicate the structure of the symptoms in the inventory, and receiver operating characteristic analysis was used to assess the performance of the inventory as a screening measure for Major Depressive Episode and Generalised Anxiety Disorder according to DSM-IV criteria. Reflecting the ascertainment of individuals in the sample as being at risk for a disorder, prevalence of individual symptoms was high although the general structure of the inventory was found to be comparable to that found in samples of both community elderly and younger medical patients. ROC analyses showed that the subscales of inventory performed satisfactorily as screening measures for anxiety or depression but lacked specificity for each disorder. In addition to providing further evidence for the utility of this inventory to detect general psychiatric distress in elderly persons, this study provides a valid means of detecting symptoms of depression and anxiety in French speaking groups.
The recent DSM-5 criteria for delirium can lead to different rates of delirium and different case identification.
The aims of this study were to determine how the new DSM-5 criteria might differ from the previous DSM-IV in detecting rates of delirium in elderly medical inpatients and to investigate the agreement between different methods, including the DSM III, DSM III-R, DSM-IV and DSM-5 criteria.
Prospective, observational study of elderly patients aged 70+ admitted under the acute medical teams in a regional general hospital. Each participant was assessed within 3 days using the DSM-5, and DSM-IV criteria plus the DRS-R98, CAM and MoCA scales.
The studied sample included 200 patients. The prevalence rates of delirium for each diagnostic system/scale were respectively for DSM-5 n=26 (13.0%), DSM-IV n=39 (19.5%), DRS-R98 n=27 (13.5%) and for CAM n=34 (17.0%). Using tetrachoric correlation coefficients the agreement between DSM-5 and DSM-IV was statistically significant (rhotetr=0.64, SE= 0.1, p<0.0001). Similar significant agreement was found between the four methods.
DSM-IV identifies more delirium cases compared to any other method and DSM-5 is the more restrictive. These classification systems identify different cases of delirium. This could have clinical, financial and research implications. However, both classification systems (and their antecedents) have significant agreement in the identification of the same concept (delirium). Clarity of diagnosis is required for classification but also has implications for prediction of outcomes, further research looking at outcomes could assist a more in depth evaluation of the DSM-5 criteria.