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According to conventional wisdom, closed-list proportional representation (CLPR) electoral systems create incentives for legislators to favor the party line over their voters’ positions. However, electoral incentives may induce party leaders to tolerate “shirking” by some legislators, even under CLPR. This study argues that in considering whose deviations from the party line should be tolerated, party leaders exploit differences in voters’ relative electoral influence resulting from malapportionment. We expect defections in roll call votes to be more likely among legislators elected from overrepresented districts than among those from other districts. We empirically test this claim using data on Argentine legislators’ voting records and a unique dataset of estimates of voters’ and legislators’ placements in a common ideological space. Our findings suggest that even under electoral rules known for promoting unified parties, we should expect strategic defections to please voters, which can be advantageous for the party’s electoral fortunes.
To assess the impact of antimicrobial stewardship programs (ASPs) in adult medical–surgical intensive care units (MS-ICUs) in Latin America.
Quasi-experimental prospective with continuous time series.
The study included 77 MS-ICUs in 9 Latin American countries.
Adult patients admitted to an MS-ICU for at least 24 hours were included in the study.
This multicenter study was conducted over 12 months. To evaluate the ASPs, representatives from all MS-ICUs performed a self-assessment survey (0–100 scale) at the beginning and end of the study. The impact of each ASP was evaluated monthly using the following measures: antimicrobial consumption, appropriateness of antimicrobial treatments, crude mortality, and multidrug-resistant microorganisms in healthcare-associated infections (MDRO-HAIs). Using final stewardship program quality self-assessment scores, MS-ICUs were stratified and compared among 3 groups: ≤25th percentile, >25th to <75th percentile, and ≥75th percentile.
In total, 77 MS-ICU from 9 Latin American countries completed the study. Twenty MS-ICUs reached at least the 75th percentile at the end of the study in comparison with the same number who remain within the 25th percentile (score, 76.1 ± 7.5 vs 28.0 ± 7.3; P < .0001). Several indicators performed better in the MS-ICUs in the 75th versus 25th percentiles: antimicrobial consumption (143.4 vs 159.4 DDD per 100 patient days; P < .0001), adherence to clinical guidelines (92.5% vs 59.3%; P < .0001), validation of prescription by pharmacist (72.0% vs 58.0%; P < .0001), crude mortality (15.9% vs 17.7%; P < .0001), and MDRO-HAIs (9.45 vs 10.96 cases per 1,000 patient days; P = .004).
MS-ICUs with more comprehensive ASPs showed significant improvement in antimicrobial utilization.
Piloting in the Panama Canal is exceptional as, due to its importance, the functions of the captains of vessels are taken over by pilots. Hence, prior to inauguration of the expanded canal, a limited number of pilots experienced on the existing canal were certified for the transit of Neopanamax vessels by means of planned and innovative individual learning. After this organisational training through operative training, with the implementation of the expanded canal in June 2016, the routine training started. Hence the learning curve in the performance of these manoeuvres will represent the growing skill acquired by both the pilots and the organisation. Given that the learning effect is measurable, this paper has the dual objective of determining two curve models: the organisation operative learning curve model and the routine learning curve model for pilots performing transit manoeuvres in the expanded Panama Canal waterways and the Cocolí and Agua Clara locks. Manoeuvre times in locks and transit in the whole of the canal were followed up continuously in the first 42 months of operation.
We used event‑related potentials to investigate how markedness impacts person agreement in English‑speaking learners of L2‑Spanish. Markedness was examined by probing agreement with both first‑person (marked) and third‑person (unmarked) subjects. Agreement was manipulated by crossing first‑person subjects with third‑person verbs and vice versa. Native speakers showed a P600 for both errors, larger for “first‑person subject + third‑person verb” violations. This aligns with claims that, when the first element in the dependency is marked (first person), the parser generates stronger predictions regarding upcoming agreeing elements using feature activation. Twenty‑two upper‑intermediate/advanced learners elicited a P600 across both errors. Learners were equally accurate detecting both errors, but the P600 was marginally reduced for “first‑person subject + third‑person verb” violations, suggesting that learners overused unmarked forms (third person) online. However, this asymmetry mainly characterized lower‑proficiency learners. Results suggest that markedness impacts L2 agreement without constraining it, although learners are less likely to use marked features top‑down.
Cognition is commonly affected in brain disorders. Non-invasive brain stimulation (NIBS) may have procognitive effects, with high tolerability. This meta-analysis evaluates the efficacy of transcranial magnetic stimulation (TMS) and transcranial Direct Current Stimulation (tDCS) in improving cognition, in schizophrenia, depression, dementia, Parkinson's disease, stroke, traumatic brain injury, and multiple sclerosis.
A PRISMA systematic search was conducted for randomized controlled trials. Hedges' g was used to quantify effect sizes (ES) for changes in cognition after TMS/tDCS v. sham. As different cognitive functions may have unequal susceptibility to TMS/tDCS, we separately evaluated the effects on: attention/vigilance, working memory, executive functioning, processing speed, verbal fluency, verbal learning, and social cognition.
We included 82 studies (n = 2784). For working memory, both TMS (ES = 0.17, p = 0.015) and tDCS (ES = 0.17, p = 0.021) showed small but significant effects. Age positively moderated the effect of TMS. TDCS was superior to sham for attention/vigilance (ES = 0.20, p = 0.020). These significant effects did not differ across the type of brain disorder. Results were not significant for the other five cognitive domains.
Our results revealed that both TMS and tDCS elicit a small trans-diagnostic effect on working memory, tDCS also improved attention/vigilance across diagnoses. Effects on the other domains were not significant. Observed ES were small, yet even slight cognitive improvements may facilitate daily functioning. While NIBS can be a well-tolerated treatment, its effects appear domain specific and should be applied only for realistic indications (i.e. to induce a small improvement in working memory or attention).
Background: Antimicrobial stewardship programs (ASPs) are useful in improving clinical outcomes in a cost-effective way and in reducing antimicrobial resistance. Objective: We sought to determine the impact of ASP in adult medical-surgical intensive care units (MS-ICUs). Methods: A multicenter study, in 77 MS-ICUs of 9 Latin-American countries, was conducted along 12 months (July 2018–June 2019). A self-assessment survey using a tool based on CDC recommendations (0–100 scale) was performed at the beginning, after 6 months, and at the end of the study. The impact of ASP was evaluated monthly using the following indicators: antimicrobial consumption (defined daily doses [DDD] per 100 patient days), appropriateness of antimicrobial prescriptions (percentage of total prescriptions), crude mortality rate (events per 100 discharges), and hospital-acquired multidrug-resistant microorganisms (MDRs) and Clostridioides difficile infections (CDI events per 1,000 patient days). These indicators were compared between MS-ICUs that reached the 75th percentile and those that maintained the 25th percentile at the final self-assessment. Results: Of all indicators evaluated, only surgical prophylaxis ≤24 hours, vancomycin therapeutic monitoring, and aminoglycosides (1 dose per day) did not show significant differences between MS-ICUs at the 75th percentile and the 25th percentile. CDI events were significantly higher at the 75th percentile MS-ICUs, probably related to better detection of C. difficile (Table 1). Conclusions: This study confirmed that MS-ICUs with more comprehensive ASPs had significantly better indicators.
The advancement of lead-free piezoelectric nanogenerators (PENGs) for flexible electronics necessitates designing more efficient systems for improved energy storage capacity. In this light, the effects of patterning BaTiO3 nanotubes within PENG on the electromechanical properties of the device were investigated. The PENGs comprised a sandwich structure of Ti–BaTiO3–graphite–Ti encapsulated in polydimethylsiloxane. Four patterns of vertically aligned BaTiO3 nanotubes were synthesized via the hydrothermal conversion of selectively-anodized TiO2 nanotubes. The highest output voltage reached up to 1.9 V. Decreasing the nanotube array spacing and pattern diameter increased the lateral displacement of BaTiO3 therefore, increasing the output voltage of the device.
An academic makerspace, home to tools and people dedicated to facilitating and inspiring a making culture, is characterized by openness, creativity, learning, design, and community. This nontraditional learning environment has found an immense increase in popularity and investment in the last decade. Further, makerspaces have been shown to be highly gendered, privileging men's and masculine understandings of making. The spike in popularity warrants deeper analysis, examining the value of these spaces for women and if learning is occurring in these spaces, specifically at higher education institutions. We implemented a phenomenologically based interviewing process to capture the making experiences of 20 women students, recruited through purposive and snowball sampling. By eliciting the narratives of women students, we captured how making, designing, and creating evolved through gendered experiences in the university makerspace. Each interview was transcribed and resulted in around 868 pages of single-spaced text transcriptions. The data were analyzed through multiple cycles of open and axial coding for common themes and patterns, where makerspaces create a culture of learning, facilitate students’ design journey, and form a laboratory for creativity. These themes forwarded the creation of a learning model that showcases how design and learning interact in the makerspace. This work demonstrates that women students are engaging learning and inspiration; developing confidence and resilience; and learning how to work with others and collaborate.
The paper presents the effects of Mexico’s conditioned cash-transfers programme (PROSPERA programme, formerly Oportunidades) on household poverty in the Northeast urban areas. The estimate was calculated using the Foster-Greer-Thorbecke Index. We use three poverty lines (i.e. food, capability, and patrimonial poverty) which costs were established by the National Assessment Council of the Social Development Policy. The results show that, in the three lines, the intensity and inequality of poverty diminished. Regarding incidence, only in extreme poverty was found a significant effect, so, there is no evidence to support that cash transfers help households to escape poverty.
Although cognitive subtypes have been suggested in schizophrenia patients, similar analyses have not been carried out in their unaffected siblings. Subtype classification may provide more insight into genetically driven variation in cognitive function.
To investigate cognitive subtypes in siblings.
Cluster analyses were performed in 654 unaffected siblings, on a cognitive battery that included tests of attention, intellectual function, and episodic memory. Resulting subtypes in the siblings were analyzed for cognitive, demographical, and clinical characteristics and compared with that of their proband.
Three sibling subtypes of cognitive function were distinguished: ‘normal’, ‘mixed’, and ‘impaired’. Normal profile siblings (n= 192) were unimpaired on cognitive tests, in contrast to their proband (n= 184). Mixed profile siblings (n= 228) and their probands (n= 222) had a more similar performance pattern. Impaired profile siblings had poorer functional outcomes (n= 234), and their profile was almost identical to that of their proband (n= 223). Probands with cognitively impaired siblings could be distinguished from other schizophrenia patients by their own cognitive performance. They also had poorer clinical characteristics, including achievement of symptomatic remission.
Unaffected siblings of patients with schizophrenia are heterogeneous with respect to cognitive function. The poorer the cognitive profile of the sibling, the higher the level of correspondence with the proband. The sibling's cognitive subtype was predictive for disease course in the proband. Distinguishing cognitive subtypes of unaffected siblings may be of relevance for genetic studies.
Suicide remains the leading cause of premature death in patients with psychotic disorders. The lifetime suicide risk for schizophrenia is approximately 10%.
This study aims to compare the suicide risk over the past decade following recent onset psychosis to findings from the eighties and nineties in the same catchment area and to identify predictors of suicide in the context of the Psychosis Recent Onset Groningen – Survey (PROGR-S).
A medical file search was carried out to determine the current status of all patients admitted between 2000 and 2009. The suicide rate was compared with a study executed in 1973-1988 in the same catchment area. Predictors of suicide were investigated using Cox regression.
The status of 424 of the 614 patients was known in July 2014. Suicide occurred in 2.4% of the patients with psychotic disorders (n=10; mean follow-up 5.6 years); 6 out of 10 suicides took place within two years. Within two decades, the suicide rate dropped from 11% (follow-up 15 years, 8.5% after 5 years) to 2.4%. The Standardized Mortality Rate (SMR) of suicides compared with the general population was 41.6. A higher age was the only significant predictor for suicide. Neuroticism, living situation, disorganized and negative symptoms, and passive coping style showed a trend for significance. A significant reduction in the suicide rate was found for people with psychosis over the past decades.
A considerable drop in suicide rate was found. Given the high SMR, suicide research should have the highest priority.
Although antipsychotics are widely prescribed, their effect of on improving poor illness insight in schizophrenia has seldom been investigated and therefore remains uncertain. This paper examines the effects of low dose haloperidol, amisulpride, olanzapine, quetiapine, and ziprasidone on insight in first-episode schizophrenia, schizoaffective disorder, or schizophreniform disorder.
The effects of five antipsychotic drugs in first episode psychosis on insight were compared in a large scale open randomized controlled trial conducted in fourteen European countries: the European First-Episode Schizophrenia Trial (EUFEST). Patients with at least minimal impairments in insight were included in the present study (n=455). Insight was assessed with item G12 of the Positive and Negative Syndrome Scale (PANSS), administered at baseline and at 1, 3, 6, 9, and 12 months after randomization.
The use of antipsychotics was associated with clear improvements in insight, independent of other symptoms. This effect was most pronounced in the first three months of treatment, with quetiapine being significantly less effective than other drugs.
Use of antipsychotics was associated with an improvement in insight, over and above their effects on other symptoms of schizophrenia. Effects of spontaneous improvement cannot be ruled out due to the lack of a placebo control group, although such a large spontaneous improvement seems unlikely. Notably, the improvement of insight was less pronounced for quetiapine compared to haloperidol, amisulpride, olanzapine, quetiapine, and ziprasidone.
Repetitive Transcranial Magnetic Stimulation (rTMS) of the frontal cortex has been shown to improve negative symptoms in schizophrenia in a number of small studies, although inconsistent results have also been reported. Neuroimaging has shown bilateral hypofrontality in schizophrenia, and rTMS may improve brain activation. We therefore aimed to investigate whether 10 Hz stimulation of the bilateral dorsolateral prefrontal cortex during 3 weeks would yield substantial treatment effects and would improvement of frontal activation.
This study concerned a multicenter double-blind randomized controlled trial in 32 patients with schizophrenia or schizoaffective disorder. All had moderate to severe negative symptoms (Positive and Negative Syndrome Scale (PANSS) negative subscale ≥ 15). Patients were randomized to a 3-week course of active or sham rTMS. Primary outcome was severity of negative symptoms as measured with the Scale for the Assessment of Negative Symptoms (SANS) and the PANSS negative symptom score. Twenty-four patients participated in the pre- and posttreatment fMRI measurement. Analyses concerned changes in brain activation as measured with functional magnetic resonance imaging (fMRI) during the Tower of London (ToL) task from pre-treatment to post-treatment.
Brain activation increased more in the active group in the right DLPFC and the right medial frontal gyrus as compared to the sham group. Different activation change was also found in the left posterior cingulate, with decreased activation in the active and increased activation in the sham group. The changes in brain activation were accompanied by a significant improvement of negative symptoms in the treatment group (p=0.04).
Our findings suggest that treatment with rTMS over the DLPFC may potentially increase task-related activation in frontal areas and improve negative symptoms in patients with schizophrenia.
To complete an up-to-date meta-analysis of studies investigating the correlation between insight and various measures of neurocognition in psychosis.
We completed a comprehensive literature search using Pubmed and ‘Web of Science’. After applying inclusion and exclusion criteria we isolated 34 papers published on this topic since 2004. This list was then added to those published prior to 2004 that had been found in an earlier meta-analysis performed by our group to give a complete collection of 69 papers. Metaanalysis of data was performed in the Comprehensive Meta-Analysis software using random effects models.
Overall our sample included 5127 patients with psychosis across 69 studies. We performed analyses for overall cognition, IQ, memory, executive function and specifically the Wisconsin Card Sorting Test (WCST). We found a small but highly significant correlation between insight and each measure of neurocognition in all patients with psychosis (mean weighted r = 0.13–0.16 across domains, p < 0.001). When restricted to those patients with diagnosis of schizophrenia (n = 1708) the strength of correlation in each domain increased slightly (mean weighted r = 0.14–0.18, p < 0.01). We found no evidence of significant publication bias.
In this comprehensive meta-analysis we found a small but robust correlation between insight and a variety of neurocognitive domains in patients with psychosis. We believe that this data supports the role of neurocognitive processes in some aspects of insight but believe that a more precise experimental approach is required to elucidate the exact mechanisms of this relationship.
Factor analyses of large datasets have established two dimensions of negative symptoms: expressive deficits and a motivation. This distinction is of relevance as the dimensions differ in their cognitive and clinical correlates (e.g. with regard to functional outcome). Using functional MRI, we examined the neural correlates of the two negative symptom dimensions with brain activation during social-emotional evaluation. Patients with schizophrenia (n = 38) and healthy controls (n = 20) performed the Wall of Faces task during fMRI, which measures emotional ambiguity in a social context by presenting an array of faces with varying degrees of consistency in emotional expressions. More specifically, appraisal of facial expressions under uncertainty. We found severity of expressive deficits to be negatively correlated with activation in thalamic, prefrontal, precentral, parietal and temporal brain areas during emotional ambiguity (appraisal of facial expressions in an equivocal versus an unequivocal condition). No association was found for a motivation with these neural correlates, in contrast to a previous fMRI study in which we found a motivation to be associated with neural correlates of executive (planning) performance. We also evaluated the effects of medication and neurostimulation (rTMS treatment over the lateral prefrontal cortex) on activation during the social–emotional ambiguity task. The medication comparison concerned an RCT of aripiprazole versus risperidone. Compared to risperidone, aripiprazole showed differential involvement of frontotemporal and frontostriatal circuits in social-emotional ambiguity. We conclude that deconstruction of negative symptoms into more homogeneous components and investigating underlying neurocognitive mechanisms can potentially shed more light on their nature and may ultimately yield clues for targeted treatment.
Early-onset first-episode psychosis (FEP) and high functioning autism spectrum disorders (ASD) are complex neuro–developmental disorders that share symptomatology but it is not clear if they also share neurobiological abnormalities (Chisholm et al., 2015). We examined thickness, surface area and volume in a direct comparison of children and adolescents with FEP (onset before 18 years), high-functioning ASD, and healthy subjects.
Magnetic resonance imaging scans of 85 participants (30 ASD, 29 FEP, 26 healthy controls, age range 10–18 years) were obtained from the same MR scanner using the same acquisition protocol. The FreeSurfer analysis suite was used to quantify vertex-wise estimates of the metrics thickness, surface area, and volume.
ASD and FEP had spatially overlapping insular deficits for each metric. The transdiagnostic overlap of deficits was greatest for volume (55% of all insular vertices) and smallest for thickness (18%). Insular thickness and surface area deficits did not overlap in ASD and overlapped only in 8% of all insular vertices in FEP.
Morphological insular deficits are common to FEP and high functioning ASD when compared to healthy participants. The pattern of deficits was similar in both disorders, i.e. a largely non-overlap of insular thickness and surface area. The non-overlap provides further evidence that these metrics represent two independent outcomes of corticogenesis, both of which are affected in FEP and ASD.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Approximately 50% of patients with schizophrenia shows deficits in motivation and initiation of goal-directed behavior, which are suggestive of reward system dysfunction. We conducted a meta-analysis of neuroimaging studies reporting on the neural correlates of reward processing and negative symptoms in schizophrenia. A significant mean weighted correlation was observerd, revealing deficits in activation of reward neurocircuitry. A more specific findings is comprised activation of the ventral striatum, involved in anticipation of reward, and structures that play a critical role in the ability to represent the value of outcomes and plans. In a study of VTA connectivity in the resting state in a large group of patients with schizophrenia, we found reduced connectivity with lateral prefrontal, temporal and parietal regions to be associated with higher degrees of apathy. Apathy belongs to the most debilitating symptoms of schizophrenia and represents a significant unmet need in its treatment. Quantitative integration of published findings suggests that treatment with noninvasive magnetic brain stimulation can improve negative symptoms. Previous PET-studies have shown that such stimulation may target circuits with dopaminergic innervation. A behavioral treatment approach that may also target reward-related circuits will also be discussed briefly. It can be concluded that recent results regarding reward and motivated behavior in schizophrenia have clinical implications and may help develop novel treatment strategies.