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After more than half a century since their unexpected discovery and identification as neutron stars, the observation and understanding of pulsars touches upon many areas of astronomy and astrophysics. The literature on pulsars is vast and the observational techniques used now cover the whole of the electromagnetic spectrum from radio to gamma-rays. Now in its fifth edition, this volume has been reorganised and features new material throughout. It provides an introduction in historical and physical terms to the many aspects of neutron stars, including condensed matter, physics of the magnetosphere, supernovae and the development of the pulsar population, propagation in the interstellar medium, binary stars, gravitation and general relativity. The current development of a new generation of powerful radio telescopes, designed with pulsar research in mind, makes this survey and guide essential reading for a growing body of students and astronomers.
• Immigration and family-building have contributed to the rapid growth of Scotland's minority ethnic groups who, by 2011, numbered 850,000, or 16 per cent of Scotland's residents.
• The largest minority is ‘White: Other British’ numbering 417,000 in 2011, an increase of 10 per cent over the decade. About three-quarters of this group were born in England.
• Each minority group increased its population during the last decade.
• The African population grew rapidly, from 5,000 in 2001 to 30,000 in 2011. This growth was mainly from immigration, and was focused on areas beyond those where African people had mainly lived before.
• Other minority populations also dispersed across Scotland during the decade, growing faster outside of those areas in which they were most likely to be resident in 2001. The one exception is the Chinese population that has grown most in the student areas near universities where it was already concentrated.
• Change in the census question itself has added diversity, now identifying the Polish population, for example. At 61,000, they are the second largest minority in 2011.
• One in six of Scotland's households of two or more people have more than one ethnicity represented.
• Individuals with a ‘Mixed or multiple’ ethnic group number 20,000 people, or 0.4 per cent of the population.
• Over half of Scotland's residents in 2011 who were born outside the UK had arrived in 2004 or more recently. Immigration has increased more rapidly in Scotland in the past decade than in the rest of Britain.
• Scotland's diversity has increased both overall and in every local authority district. All of Edinburgh's population and two-thirds of Glasgow's population live in wards that are more diverse than Scotland as a whole. Both have become more diverse, and their diversity has spread more evenly through their cities, as it has through Scotland as a whole.
It has been recognised for some time that there are distinctive aspects to ethnic diversity in Scotland. The reasons for this are, in no small part, historical: significant Irish immigration to Scotland in the 19th century, especially to the west of Scotland, created a large migrant labour force, as did the migration southwards of displaced Highlanders who were seen as being culturally, if not ‘racially’, distinct by lowland Scots.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) has high morbidity and mortality in older adults and people with dementia. Infection control and prevention measures potentially reduce transmission within hospitals.
We aimed to replicate our earlier study of London mental health in-patients to examine changes in clinical guidance and practice and associated COVID-19 prevalence and outcomes between COVID-19 waves 1 and 2 (1 March to 30 April 2020 and 14 December 2020 to 15 February 2021).
We collected the 2 month period prevalence of wave 2 of COVID-19 in older (≥65 years) in-patients and those with dementia, as well as patients’ characteristics, management and outcomes, including vaccinations. We compared these results with those of our wave 1 study.
Sites reported that routine testing and personal protective equipment were available, and routine patient isolation on admission occurred throughout wave 2. COVID-19 infection occurred in 91/358 (25%; 95% CI 21–30%) v. 131/344, (38%; 95% CI 33–43%) P < 0.001 in wave 1. Hospitals identified more asymptomatic carriers (26/91; 29% v. 16/130; 12%) and fewer deaths (12/91; 13% v. 19/131; 15%; odds ratio = 0.92; 0.37–1.81) compared with wave 1. The patient vaccination uptake rate was 49/58 (85%).
Patients in psychiatric in-patient settings, mostly admitted without known SARS-CoV-2 infection, had a high risk of infection compared with people in the community but lower than that during wave 1. Availability of infection control measures in line with a policy of parity of esteem between mental and physical health appears to have lowered within-hospital COVID-19 infections and deaths. Cautious management of vulnerable patient groups including mental health patients may reduce the future impact of COVID-19.
The Canadian Nosocomial Infection Surveillance Program conducted point-prevalence surveys in acute-care hospitals in 2002, 2009, and 2017 to identify trends in antimicrobial use.
Eligible inpatients were identified from a 24-hour period in February of each survey year. Patients were eligible (1) if they were admitted for ≥48 hours or (2) if they had been admitted to the hospital within a month. Chart reviews were conducted. We calculated the prevalence of antimicrobial use as follows: patients receiving ≥1 antimicrobial during survey period per number of patients surveyed × 100%.
In each survey, 28−47 hospitals participated. In 2002, 2,460 (36.5%; 95% CI, 35.3%−37.6%) of 6,747 surveyed patients received ≥1 antimicrobial. In 2009, 3,566 (40.1%, 95% CI, 39.0%−41.1%) of 8,902 patients received ≥1 antimicrobial. In 2017, 3,936 (39.6%, 95% CI, 38.7%−40.6%) of 9,929 patients received ≥1 antimicrobial. Among patients who received ≥1 antimicrobial, penicillin use increased 36.8% between 2002 and 2017, and third-generation cephalosporin use increased from 13.9% to 18.1% (P < .0001). Between 2002 and 2017, fluoroquinolone use decreased from 25.7% to 16.3% (P < .0001) and clindamycin use decreased from 25.7% to 16.3% (P < .0001) among patients who received ≥1 antimicrobial. Aminoglycoside use decreased from 8.8% to 2.4% (P < .0001) and metronidazole use decreased from 18.1% to 9.4% (P < .0001). Carbapenem use increased from 3.9% in 2002 to 6.1% in 2009 (P < .0001) and increased by 4.8% between 2009 and 2017 (P = .60).
The prevalence of antimicrobial use increased between 2002 and 2009 and then stabilized between 2009 and 2017. These data provide important information for antimicrobial stewardship programs.
Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery.
Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2–20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5–85, overweight 85–95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis.
There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive–inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias.
Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.
Accumulating evidence suggests that alterations in inflammatory biomarkers are important in depression. However, previous meta-analyses disagree on these associations, and errors in data extraction may account for these discrepancies.
PubMed/MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched from database inception to 14 January 2020. Meta-analyses of observational studies examining the association between depression and levels of tumor necrosis factor-α (TNF-α), interleukin 1-β (IL-1β), interleukin-6 (IL-6), and C-reactive protein (CRP) were eligible. Errors were classified as follows: incorrect sample sizes, incorrectly used standard deviation, incorrect participant inclusion, calculation error, or analysis with insufficient data. We determined their impact on the results after correction thereof.
Errors were noted in 14 of the 15 meta-analyses included. Across 521 primary studies, 118 (22.6%) showed the following errors: incorrect sample sizes (20 studies, 16.9%), incorrect use of standard deviation (35 studies, 29.7%), incorrect participant inclusion (7 studies, 5.9%), calculation errors (33 studies, 28.0%), and analysis with insufficient data (23 studies, 19.5%). After correcting these errors, 11 (29.7%) out of 37 pooled effect sizes changed by a magnitude of more than 0.1, ranging from 0.11 to 1.15. The updated meta-analyses showed that elevated levels of TNF- α, IL-6, CRP, but not IL-1β, are associated with depression.
These findings show that data extraction errors in meta-analyses can impact findings. Efforts to reduce such errors are important in studies of the association between depression and peripheral inflammatory biomarkers, for which high heterogeneity and conflicting results have been continuously reported.
Human activities in forests contribute more than one-fifth of global greenhouse gas emissions. Forests face serious risks from climate change due to more intense and frequent mega-fires, drought and loss of ecosystem resilience resulting from biodiversity loss, which in turn impact the provision of ecosystem services. Priorities for mitigation of, and adaptation to, climate change are: avoiding emissions by protecting carbon stocks in natural ecosystems; sequestering carbon through restoration of degraded ecosystems; and reducing emissions through transferring wood production to plantations on existing cleared land, improving efficiency of wood processing, reducing waste, producing higher value wood products with longer lifetimes, substituting emissions-intensive building materials with wood, and recycling. Many co-benefits arise from forest management strategies for mitigation through protection and restoration. Effective governance and policy are critical to supporting and incentivising these mitigation and adaptation strategies to invest in restoration of native forests and development of plantation forests. Alternative policy development frameworks are discussed.
As the US faced its lowest levels of reported trust in government, the COVID-19 crisis revealed the essential service that various federal agencies provide as sources of information. This Element explores variations in trust across various levels of government and government agencies based on a nationally-representative survey conducted in March of 2020. First, it examines trust in agencies including the Department of Health and Human Services, state health departments, and local health care providers. This includes variation across key characteristics including party identification, age, and race. Second, the Element explores the evolution of trust in health-related organizations throughout 2020 as the pandemic continued. The Element concludes with a discussion of the implications for agency-specific assessments of trust and their importance as we address historically low levels of trust in government. This title is also available as Open Access on Cambridge Core.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
A number of community based surveys have identified an increase in psychological symptoms and distress but there has been no examination of symptoms at the more severe end of the mental health spectrum.
We aimed to analyse numbers and types of psychiatric presentations to inform planning for future demand on mental health services in light of the COVID-19 pandemic.
We analysed electronic data between January and April 2020 for 2534 patients referred to acute psychiatric services, and tested for differences in patient demographics, symptom severity and use of the Mental Health Act 1983 (MHA), before and after lockdown. We used interrupted time-series analyses to compare trends in emergency department and psychiatric presentations until December 2020.
There were 22% fewer psychiatric presentations the first week and 48% fewer emergency department presentations in the first month after lockdown initiated. A higher proportion of patients were detained under the MHA (22.2 v. 16.1%) and Mental Capacity Act 2005 (2.2 v. 1.1%) (χ2(2) = 16.3, P < 0.0001), and they experienced a longer duration of symptoms before seeking help from mental health services (χ2(3) = 18.6, P < 0.0001). A higher proportion of patients presented with psychotic symptoms (23.3 v. 17.0%) or delirium (7.0 v. 3.6%), and fewer had self-harm behaviour (43.8 v. 52.0%, χ2(7) = 28.7, P < 0.0001). A higher proportion were admitted to psychiatric in-patient units (22.2 v. 18.3%) (χ2(6) = 42.8, P < 0.0001) after lockdown.
UK lockdown resulted in fewer psychiatric presentations, but those who presented were more likely to have severe symptoms, be detained under the MHA and be admitted to hospital. Psychiatric services should ensure provision of care for these patients as well as planning for those affected by future COVID-19 waves.
Since 2008, academics and policymakers have frequently debated why bond rating agencies such as Moody's, S&P, and Fitch enjoy considerable power and influence. The 2008 financial crisis focused our attention on the bond rating agencies that had previously categorized mortgage-backed securities as investment grade. Scholars have attributed the power enjoyed by the rating agencies to regulations that confer a privileged status on those agencies that are designated as nationally recognized statistical rating organizations (NRSROs) by the U.S. Securities and Exchange Commission (SEC). While these authors mention in passing that the relevant regulation went into effect in 1975, none has conducted archival research to examine why this regulation was introduced at that time. This article is the first historical investigation of the creation of this crucial regulation, which entrenched the concept of the NRSRO in federal securities law. It shows that the SEC mandated the use of NRSRO-created ratings even though SEC officials vigorously debated whether it was wise for the commission to endorse ratings produced by agencies that operate on the basis of the controversial issuer-pay model. This article contributes to our understanding of the SEC's role in the development of the distinctive features of American capitalism.
Primary health care (PHC) includes both primary care (PC) and essential public health (PH) functions. While much is written about the need to coordinate these two aspects, successful integration remains elusive in many countries. Furthermore, the current global pandemic has highlighted many gaps in a well-integrated PHC approach. Four key actions have been recognized as important for effective integration.
A survey of PC stakeholders (clinicians, researchers, and policy-makers) from 111 countries revealed many of the challenges encountered when facing the pandemic without a coordinated effort between PC and PH functions. Participants’ responses to open-ended questions underscored how each of the key actions could have been strengthened in their country and are potential factors to why a strong PC system may not have contributed to reduced mortality.
By integrating PC and PH greater capacity to respond to emergencies may be possible if the synergies gained by harmonizing the two are realized.
The Bronze Age in Britain is now a term often used to include both the first use of copper c. 2400 bc and also tin-bronze from c. 2100 bc, all of which required the extensive use of copper. Prehistoric mining for this metal has been identified in surface and underground workings in Parys Mine, Mynydd Parys, Anglesey, although almost all of the surface workings are now obscured by the extensive deep spoil from more recent mining in the industrial period. These copper-bearing ores are in bedded lodes, together with some intruded vein deposits. The Bronze Age workings have been exposed underground where they have been intersected by the early 19th century industrial workings on and above the 16 fathom and 20 fathom levels in the Parys Mine. Spoil exposures contain stone hammers (‘mauls’), wood fragments, and charcoal; samples of the latter have been radiocarbon dated with chronological modelling suggesting activity took place in the first half of the 2nd millennium cal bc. Although relatively limited in extent, these important prehistoric mining sites are among the earliest found in the UK. They have survived due to their protection from surface erosion and limited accessibility.
Coronavirus disease (COVID-19) has been identified as an acute respiratory illness leading to severe acute respiratory distress syndrome. As the disease spread, demands on health care systems increased, specifically the need to expand hospital capacity. Alternative care hospitals (ACHs) have been used to mitigate these issues; however, establishing an ACH has many challenges. The goal of this session was to perform systems testing, using a simulation-based evaluation to identify areas in need of improvement.
Four simulation cases were designed to depict common and high acuity situations encountered in the ACH, using a high technology simulator and standardized patient. A multidisciplinary observer group was given debriefing forms listing the objectives, critical actions, and specific areas to focus their attention. These forms were compiled for data collection.
Logistical, operational, and patient safety issues were identified during the simulation and compiled into a simulation event report. Proposed solutions and protocol changes were made in response to the identified issues.
Simulation was successfully used for systems testing, supporting efforts to maximize patient care and provider safety in a rapidly developed ACH. The simulation event report identified operational deficiencies and safety concerns directly resulting in equipment modifications and protocol changes.
With multiple sclerosis (MS) affecting women two to three times more often than men, and an average age of onset of 20–50 years, a good portion of MS patients will be women of reproductive potential. Therefore, it is critical to develop an understanding of how the disease affects reproduction and menopause, and how it might impact their life goals. Over the course of this chapter, epidemiological risk factors based on gender, pregnancy, and the need for family planning will be reviewed.