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The radical or underlying title of the Crown to all lands in the kingdom is a feature of English common law derived from Anglo-Norman feudal doctrines. When British sovereignty was proclaimed over new plantations or colonies, following the reasoning of William Blackstone, English law was part and parcel of the birthright of British subjects (whether English, Welsh, Scottish or Irish) who settled in ‘uncultivated’ distant lands. Crown title, though, is now said by the Supreme Court of Canada “to be burdened by the pre-existing legal rights of Aboriginal people who occupied and used the land prior to European arrival.” [Tsilhqot’in Nation 2014) Development of what is called the ‘common law doctrine of aboriginal title’ – though not derived from English common law – is a feature of case precedents in Canada, Australia and New Zealand in recent decades. Courts in these jurisdictions have consistently relied on proclamations of British sovereignty as the origin point for the radical title of the Crown, and the Crown’s right to extinguish native title. The comparative aspect of the paper investigates divergent judicial responses to the status and relevance of pre-existing indigenous norms and values. These range from terra nullius outright rejection of their relevance, to limited acceptance of usufructuary and possessory rights, to a broader acceptance that native title must be understood in the light of indigenous understandings.
ABSTRACT IMPACT: A machine learning approach using electronic health records can combine descriptive, population-level factors of pressure injury outcomes. OBJECTIVES/GOALS: Pressure injuries cause 60,000 deaths and cost $26 billion annually in the US, but prevention is laborious. We used clinical data to develop a machine learning algorithm for predicting pressure injury risk and prescribe the timing of intervention to help clinicians balance competing priorities. METHODS/STUDY POPULATION: We obtained 94,745 electronic health records with 7,000 predictors to calibrate a predictive algorithm of pressure injury risk. Machine learning was used to mine features predicting changes in pressure injury risk; random forests outperformed neural networks, boosting and bagging in feature selection. These features were fit to multilevel ordered logistic regression to create an algorithm that generated empirical Bayes estimates informing a decision-rule for follow-up based on individual risk trajectories over time. We used cross-validation to verify predictive validity, and constrained optimization to select a best-fit algorithm that reduced the time required to trigger patient follow-up. RESULTS/ANTICIPATED RESULTS: The algorithm significantly improved prediction of pressure injury risk (p<0.001) with an area under the ROC curve of 0.60 compared to the Braden Scale, a traditional clinician instrument of pressure injury risk. At a specificity of 0.50, the model achieved a sensitivity of 0.63 within 2.5 patient-days. Machine learning identified categorical increases in risk when patients were prescribed vasopressors (OR=16.4, p<0.001), beta-blockers (OR=4.8, p<0.001), erythropoietin stimulating agents (OR=3.0, p<0.001), or were ordered a urinalysis screen (OR=9.1, p<0.001), lipid panel (OR=5.7, p<0.001) or pre-albumin panel (OR=2.0, p<0.001). DISCUSSION/SIGNIFICANCE OF FINDINGS: This algorithm could help hospitals conserve resources within a critical period of patient vulnerability for pressure injury not reimbursed by Medicare. Savings generated by this approach could justify investment in machine learning to develop electronic warning systems for many iatrogenic injuries.
Recently, artificial intelligence-powered devices have been put forward as potentially powerful tools for the improvement of mental healthcare. An important question is how these devices impact the physician-patient interaction.
Aifred is an artificial intelligence-powered clinical decision support system (CDSS) for the treatment of major depression. Here, we explore the use of a simulation centre environment in evaluating the usability of Aifred, particularly its impact on the physician–patient interaction.
Twenty psychiatry and family medicine attending staff and residents were recruited to complete a 2.5-h study at a clinical interaction simulation centre with standardised patients. Each physician had the option of using the CDSS to inform their treatment choice in three 10-min clinical scenarios with standardised patients portraying mild, moderate and severe episodes of major depression. Feasibility and acceptability data were collected through self-report questionnaires, scenario observations, interviews and standardised patient feedback.
All 20 participants completed the study. Initial results indicate that the tool was acceptable to clinicians and feasible for use during clinical encounters. Clinicians indicated a willingness to use the tool in real clinical practice, a significant degree of trust in the system's predictions to assist with treatment selection, and reported that the tool helped increase patient understanding of and trust in treatment. The simulation environment allowed for the evaluation of the tool's impact on the physician–patient interaction.
The simulation centre allowed for direct observations of clinician use and impact of the tool on the clinician–patient interaction before clinical studies. It may therefore offer a useful and important environment in the early testing of new technological tools. The present results will inform further tool development and clinician training materials.
In 2019, a 42-year-old African man who works as an Ebola virus disease (EVD) researcher traveled from the Democratic Republic of Congo (DRC), near an ongoing EVD epidemic, to Philadelphia and presented to the Hospital of the University of Pennsylvania Emergency Department with altered mental status, vomiting, diarrhea, and fever. He was classified as a “wet” person under investigation for EVD, and his arrival activated our hospital emergency management command center and bioresponse teams. He was found to be in septic shock with multisystem organ dysfunction, including circulatory dysfunction, encephalopathy, metabolic lactic acidosis, acute kidney injury, acute liver injury, and diffuse intravascular coagulation. Critical care was delivered within high-risk pathogen isolation in the ED and in our Special Treatment Unit until a diagnosis of severe cerebral malaria was confirmed and EVD was definitively excluded.
This report discusses our experience activating a longitudinal preparedness program designed for rare, resource-intensive events at hospitals physically remote from any active epidemic but serving a high-volume international air travel port-of-entry.
Reconstructions of prehistoric vegetation composition help establish natural baselines, variability, and trajectories of forest dynamics before and during the emergence of intensive anthropogenic land use. Pollen–vegetation models (PVMs) enable such reconstructions from fossil pollen assemblages using process-based representations of taxon-specific pollen production and dispersal. However, several PVMs and variants now exist, and the sensitivity of vegetation inferences to PVM selection, variant, and calibration domain is poorly understood. Here, we compare the reconstructions, parameter estimates, and structure of a Bayesian hierarchical PVM, STEPPS, both to observations and to REVEALS, a widely used PVM, for the pre–Euro-American settlement-era vegetation in the northeastern United States (NEUS). We also compare NEUS-based STEPPS parameter estimates to those for the upper midwestern United States (UMW). Both PVMs predict the observed macroscale patterns of vegetation composition in the NEUS; however, reconstructions of minor taxa are less accurate and predictions for some taxa differ between PVMs. These differences can be attributed to intermodel differences in structure and parameter estimates. Estimates of pollen productivity from STEPPS broadly agree with estimates produced for use in REVEALS, while comparison between pollen dispersal parameter estimates shows no significant relationship. STEPPS parameter estimates are similar between the UMW and NEUS, suggesting that STEPPS parameter estimates are transferable between floristically similar regions and scales.
Advocates of constitutional reform often argue that a key obstacle to political change is lack of public understanding about constitutional order and the absence of conditions necessary for promoting measured, dispassionate and rational reflection on existing constitutional arrangements, or what political theorists term ‘deliberative democracy’. These problems are even more pronounced in political systems based on the Westminster model of constitutional monarchy, where neither the constitution nor the Crown are concepts easy to grasp. In this chapter we critique the simplistic and rationalistic assumptions behind arguments for deliberative democracy. As we show, what constitutes public engagement in matters of constitutional importance is sometimes a matter of debate and often turns out, on closer analysis, to be more theatrical and performative than deliberative. In making our argument, we draw on examples from New Zealand, a country that has had three major constitutional deliberations since 2005, including an unsuccessful referendum on whether to change its national flag. These examples illustrate wider problems of how to engage the public in meaningful constitutional debates when the constitution itself is so opaque.
In Westminster constitutions based on the supremacy of Parliament there remain a number of important governmental powers derived purely from royal prerogatives. They can be potent political weapons allowing the executive government to act without democratic accountability. Some reserve powers are exercised by the monarch or vice-regal representative – and not without controversy in some instances. Most prerogative powers are vested in Cabinet and in ministers responsible for entering, ratifying and withdrawing from treaties, declaring war and dispatching armed forces personnel to theatres of war, and dealing with British subjects in directly ruled Crown overseas territories. Walter Bagehot is invariably the primary authority cited on the role of the sovereign in a constitutional monarchy even though his views did not accurately reflect reality in 1867, and may still disguise reality today. The executive frequently finds it useful and necessary – indeed ‘efficient’ in Bagehot’s terms – to invoke prerogative powers. The Chilcot Iraq inquiry; litigation concerning involuntary removal of British subjects from Diego Garcia for a US military base; and the role or prerogative in the Brexit decision-making are among the cases studies in this chapter.
Part I examines the nature and development of the Crown, and this chapter analyses key moments in the transition from feudalist royal autocracy to constitutional monarchy in England, focussing on Crown prerogative and reserve powers. Parliament's increased role in the Tudor constitution in the sixteenth century was the precursor to further dramatic constitutional changes throughout the seventeenth-century Stuart era. By the end of that century, royal absolutism had been replaced by the emergence of a constitutional order with parliamentary supremacy the cornerstone. Myths and legal fictions played a role in the incremental evolution of Westminster parliamentary democracies and an indivisible Crown. In the twentieth century a Commonwealth of Nations emerged. Now we have multiple versions of the Queen’s ‘two bodies'. Each of the realms over which Elizabeth II reigns as sovereign is a distinct body politic. Some of those polities have federal structures, and the states or provinces are additional separate and discrete Queen’s bodies within one realm. New Zealand retains perhaps the most ‘pure’ form of Westminster parliamentary sovereignty and parliamentary sovereignty anywhere in the world.
As many pundits and politicians argue, Australia, Canada, New Zealand and the United Kingdom may be on the cusp of major constitutional change. As the reign of Queen Elizabeth draws to a close, both the role of monarchy and the Westminster system of constitutional monarchy are increasingly being called into question as anachronistic and no longer fit for purpose. Against a background of calls for constitutional reform this chapter asks, what is the Crown’s future? What can we conclude about its shapeshifting nature and divisibility? For whom is it a ‘convenient’ or useful fiction? We also explore how it embodies and personifies state authority and how people make sense of it in the different realms. Finally, we address the question of which realm is most likely to be the first to adopt a republican constitution. We address these questions from both theoretical and ethnographic perspectives. We highlight the Crown’s complex and sometimes contradictory meanings, the utility of its ambiguity and how its ability to bridge the sacred and the profane sustains its constitutional legitimacy.
The Crown stands at the heart of the New Zealand, British, Australian and Canadian constitutions as the ultimate source of legal authority and embodiment of state power. A familiar icon of the Westminster model of government, it is also an enigma. Even constitutional experts struggle to define its attributes and boundaries: who or what is the Crown and how is it embodied? Is it the Queen, the state, the government, a corporation sole or aggregate, a relic of feudal England, a metaphor, or a mask for the operation of executive power? How are its powers exercised? How have the Crowns of different Commonwealth countries developed? The Shapeshifting Crown combines legal and anthropological perspectives to provide novel insights into the Crown's changing nature and its multiple, ambiguous and contradictory meanings. It sheds new light onto the development of the state in postcolonial societies and constitutional monarchy as a cultural system.