To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
To determine the proportion of hospitals that implemented 6 leading practices in their antimicrobial stewardship programs (ASPs). Design: Cross-sectional observational survey.
Advance letters and electronic questionnaires were initiated February 2020. Primary outcomes were percentage of hospitals that (1) implemented facility-specific treatment guidelines (FSTG); (2) performed interactive prospective audit and feedback (PAF) either face-to-face or by telephone; (3) optimized diagnostic testing; (4) measured antibiotic utilization; (5) measured C. difficile infection (CDI); and (6) measured adherence to FSTGs.
Of 948 hospitals invited, 288 (30.4%) completed the questionnaire. Among them, 82 (28.5%) had <99 beds, 162 (56.3%) had 100–399 beds, and 44 (15.2%) had ≥400+ beds. Also, 230 (79.9%) were healthcare system members. Moreover, 161 hospitals (54.8%) reported implementing FSTGs; 214 (72.4%) performed interactive PAF; 105 (34.9%) implemented procedures to optimize diagnostic testing; 235 (79.8%) measured antibiotic utilization; 258 (88.2%) measured CDI; and 110 (37.1%) measured FSTG adherence. Small hospitals performed less interactive PAF (61.0%; P = .0018). Small and nonsystem hospitals were less likely to optimize diagnostic testing: 25.2% (P = .030) and 21.0% (P = .0077), respectively. Small hospitals were less likely to measure antibiotic utilization (67.8%; P = .0010) and CDI (80.3%; P = .0038). Nonsystem hospitals were less likely to implement FSTGs (34.3%; P < .001).
Significant variation exists in the adoption of ASP leading practices. A minority of hospitals have taken action to optimize diagnostic testing and measure adherence to FSTGs. Additional efforts are needed to expand adoption of leading practices across all acute-care hospitals with the greatest need in smaller hospitals.
In the final books of the Morte Darthur Lancelot, gravely wounded, and Lavayne, Elaine of Ascolat's brother, find welcome and succour at the residence of a well-to-do hermit. This incident of hospitality and medical care incites direct authorial comment from Malory, in one of his always scornful remarks on the decline of standards ‘nowadays’. He writes:
For in thos dayes hit was nat the gyse as ys nowadayes; for there were none ermytis in tho dayes but that they had bene men of worship and of prouesse, and tho ermytes hylde grete householdis and refreysshed people that were in distresse.
The hospitality of hermits is a mainstay of the questing knight, throughout the Morte and indeed throughout the vast Arthurian archive, in spite of the oxymoronic qualities of the expression: the primary meaning of the word eremite is a solitary religious, while ‘hospitality’ inevitably implies welcome, good manners, conviviality and gregariousness. Hospitality is never solitary. Hermitry is also a well-known retirement project of knights errant, best expressed by Guy of Warwick; in fact, the hermit in this instance is a ‘knyght armyte’, Sir Bawdwyn of Bretayne. And while not a hermit precisely, Lancelot will also come to his final days as a religious recluse in the Morte. The notion of a solitary religious with a great household may even seem slightly ridiculous, insofar as it expresses a fantasy of keeping it all while giving it all up.
The hospitable hermit is a feature of the mysterious geography of the quest world with its landscape of forests and uninhabited lands; he is especially prominent in the more extremely devastated landscape of the Grail Quest. But the very structure of errancy, of knights riding forth into the forest of adventure, means that such a knight also throws himself into a world where hospitality will be necessary, whether from hermits or, more commonly, from the knights and castle keeps that dot this mythic geography.
The law of hospitality is implied and assumed throughout Arthurian romance. An ancient law, it includes: the duty to welcome the stranger, the obligation to give and receive courteously, and the suspension of hostility, on the part of both host and guest.
Multiple micronutrient deficiencies are widespread in Ethiopia. However, the distribution of Se and Zn deficiency risks has previously shown evidence of spatially dependent variability, warranting the need to explore this aspect for wider micronutrients. Here, blood serum concentrations for Ca, Mg, Co, Cu and Mo were measured (n 3102) on samples from the Ethiopian National Micronutrient Survey. Geostatistical modelling was used to test spatial variation of these micronutrients for women of reproductive age, who represent the largest demographic group surveyed (n 1290). Median serum concentrations were 8·6 mg dl−1 for Ca, 1·9 mg dl−1 for Mg, 0·4 µg l−1 for Co, 98·8 µg dl−1 for Cu and 0·2 µg dl−1 for Mo. The prevalence of Ca, Mg and Co deficiency was 41·6 %, 29·2 % and 15·9 %, respectively; Cu and Mo deficiency prevalence was 7·6 % and 0·3 %, respectively. A higher prevalence of Ca, Cu and Mo deficiency was observed in north western, Co deficiency in central and Mg deficiency in north eastern parts of Ethiopia. Serum Ca, Mg and Mo concentrations show spatial dependencies up to 140–500 km; however, there was no evidence of spatial correlations for serum Co and Cu concentrations. These new data indicate the scale of multiple mineral micronutrient deficiency in Ethiopia and the geographical differences in the prevalence of deficiencies suggesting the need to consider targeted responses during the planning of nutrition intervention programmes.
Reflex-mediated syncope occurs in 15% of children and young adults. In rare instances, pacemakers are required to treat syncopal episodes associated with transient sinus pauses or atrioventricular block. This study describes a single centre experience in the use of permanent pacemakers to treat syncope in children and young adults.
Materials and methods:
Patients with significant pre-syncope or syncope and pacemaker implantation from 1978 to 2018 were reviewed. Data collected included the age of presentation, method of diagnosis, underlying rhythm disturbance, age at implant, type of pacemaker implanted, procedural complications and subsequent symptoms.
Fifty patients were identified. Median age at time of the first syncopal episode was 10.2 (range 0.3–20.4) years, with a median implant age of 14.9 (0.9–34.3) years. Significant sinus bradycardia/pauses were the predominant reason for pacemaker implant (54%), followed by high-grade atrioventricular block (30%). Four (8%) patients had both sinus pauses and atrioventricular block documented. The majority of patients had dual-chamber pacemakers implanted (58%), followed by ventricular pacemakers (38%). Median follow-up was 6.7 (0.4–33.0) years. Post-implant, 4 (8%) patients continued to have syncope, 7 (14%) had complete resolution of their symptoms, and the remaining reported a decrease in their pre-syncopal episodes and no further syncope. Twelve (24%) patients had complications, including two infections and eight lead malfunctions.
Paediatric patients with reflex-mediated syncope can be treated with pacing. Complication rates are high (24%); as such, permanent pacemakers should be reserved only for those in whom asystole from sinus pauses or atrioventricular block has been well documented.
A single high-fat, high-carbohydrate meal (HFHC) results in elevated postprandial glucose (GLU), triglycerides (TAG) and metabolic load index (MLI; TAG (mg/dl) + GLU (mg/dl)) that contributes to chronic disease risk. While disease risk is higher in older adults (OA) compared to younger adults (YA), the acute effects of exercise on these outcomes in OA is understudied. Twelve YA (age 23.3 ± 3.9 yrs, n = 5 M/7 F) and 12 OA (age 67·7 ± 6.0 yrs, n = 8 M/4 F) visited the laboratory in random order to complete a HFHC with no exercise (NE) or acute exercise (EX) condition. EX was performed 12 hours prior to HFHC at an intensity of 65 % of maximal heart rate to expend 75 % of the kcals consumed in HFHC (Marie Callender’s Chocolate Satin Pie; 12 kcal/kgbw; 57 % fat, 37 % CHO). Blood samples were taken at 0, 30, 60, 90 minutes, and then every hour until 6 hours post-meal. TAG levels increased to a larger magnitude in OA (Δ∼61 ± 31 %) compared to YA (Δ∼37 ± 34 %, P < 0·001), which were attenuated in EX compared to NE (P < 0·05) independent of age. There was no difference in GLU between OA and YA after the HFM, however, EX had attenuated GLU independent of age (NE: Δ∼21 ± 26 %; EX: Δ∼12 ± 18 %, P = 0·027). MLI was significantly lower after EX compared to NE in OA and YA (P < 0·001). Pre-prandial EX reduced TAG, GLU and MLI post-HFHC independent of age.
This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care.
We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted.
Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3–4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3–4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions.
When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.
The commemoration or, for the Dutch, celebration of the raid on the Medway in June 1667 drew a narrow focus on Anglo-Dutch relations in the second half of the seventeenth century. This dramatic episode was, however, just one of many encounters between the two states between 1650 and 1689 encompassing, inter alia, trade conflict and war, diplomacy and espionage, and religion. To a greater or much lesser extent all these elements were endemic during the period of the Second Anglo-Dutch War of 1665–67. The aftermath and impact of the war on the Dutch and the English reflected the complexities of international relations in early modern Europe and had significant implications for their internal politics. Priorities for the years 1667–72 and the outbreak of the Third Anglo-Dutch War were determined by a variety of often conflicting interests raising the question of how far the principal players were in control of these interests. Beyond the natural euphoria of a victory over the English at sea, and the conclusion of the treaty at Breda a few weeks later, the Dutch had to react quickly to political developments at home, challenges to their maritime trade and shifting international interests and allegiances. The English by contrast had to come to terms with a peace which confirmed their overseas conquests, but exposed the limits of the Stuart state, raising the crucial issue of the nature and role of the fiscal and administrative state under Charles II. To quote J.R. Jones, ‘One of the characteristics of the Anglo-Dutch wars that made them unique in the context of the seventeenth century was that governments in both countries had to rely on the co-operation of representative institutions.’
In the Dutch Republic one of the most visible and immediate effects of the successful enterprise was a temporary rise in the reputation of Cornelis de Witt, older brother and confederate of John de Witt, grand pensionary of the province of Holland since 1653. As a representative of the Holland city of Dordrecht, Cornelis played an active role in the management of military and naval actions and in 1664 had been scapegoated for the military withdrawal from the threat of incursions in the eastern provinces by the prince bishopric of Munster.
The duodenum lies in front of the right kidney and renal vessels, the right psoas muscle, the inferior vena cava, and the aorta (Figure 26.1).
The duodenum is approximately 25 cm in length. It is the most fixed part of the small intestine and has no mesentery. It is anatomically divided into four parts:
The superior or first portion is intraperitoneal along the anterior half of its circumference. Superiorly, the first portion is attached to the hepatoduodenal ligament. The posterior wall is associated with the gastroduodenal artery, common bile duct, and the portal vein.
The descending or second portion shares a medial border with the head of the pancreas. It is bordered posteriorly by the medial surface of the right kidney, the right renal vessels, and the inferior vena cava. The hepatic flexure and transverse colon cross anteriorly. The common bile duct and main pancreatic duct drain into the medial wall of the descending duodenum.
The transverse or third portion is also entirely retroperitoneal. Posteriorly, it is bordered by the inferior vena cava and the aorta. The superior mesenteric vessels cross in front of this portion of the duodenum.
The ascending or fourth portion of the duodenum is approximately 2.5 cm in length and is primarily retroperitoneal, except for the most distal segment. It crosses anterior to and ascends to the left of the aorta to join the jejunum at the ligament of Treitz.
The common bile duct courses laterally within the hepatodudenal ligament and lies posterior to the first portion of the duodenum and pancreatic head, becoming partially invested within the parenchyma of the pancreatic head. The main pancreatic duct then joins the common bile duct to drain into the ampulla of Vater within the second portion of the duodenum. The ampulla of Vater is located approximately 7 cm from the pylorus. The accessory pancreatic duct drains approximately 2 cm proximal to the ampulla of Vater.
The vascular supply to the duodenum is intimately associated with the head of the pancreas. The head of the pancreas and the second portion of the duodenum derive their blood supply from the anterior and posterior pancreaticoduodenal arcades (Figure 26.2). These arcades lie on the surface of the pancreas near the duodenal C loop. Attempts to separate these two organs at this location usually results in ischemia of the duodenum.
Objectives: Caregivers of youth with heavy prenatal alcohol exposure report impaired communication, which can significantly impact quality of life. Using data collected as part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD), we examined whether cognitive variables predict communication ability of youth with histories of heavy prenatal alcohol exposure. Methods: Subjects (ages 10–16 years) comprised two groups: adolescents with heavy prenatal alcohol exposure (AE) and non-exposed controls (CON). Selected measures of executive function (NEPSY, Delis-Kaplan Executive Function System), working memory (CANTAB), and language were tested in the child, while parents completed communication ratings (Vineland Adaptive Behavior Scales – Second Edition). Separate multiple regression analyses determined which cognitive domains predicted communication ability. A final, global model of communication comprised the three cognitive models. Results: Spatial Working Memory and Inhibition significantly contributed to communication ability across groups. Twenty Questions performance related to communication ability in the CON group only while Word Generation performance related to communication ability in the AE group only. Effects remained significant in the global model, with the exception of Spatial Working Memory. Conclusions: Both groups displayed a relation between communication and Spatial Working Memory and Inhibition. Stronger communication ability related to stronger verbal fluency in the AE group and Twenty Questions performance in the CON group. These findings suggest that alcohol-exposed adolescents may rely more heavily on learned verbal storage or fluency for daily communication while non-exposed adolescents may rely more heavily on abstract thinking and verbal efficiency. Interventions aimed at aspects of executive function may be most effective at improving communication ability of these individuals. (JINS, 2018, 24, 1026–1037)
The purpose of the study is to describe changes in mental health among women following an oil spill and to examine their association with the Deepwater Horizon oil spill (DHOS).
The Women and Their Children’s Health study followed 2038 women in Louisiana after the DHOS. Subjects were interviewed in 2012-2014 and 2014-2016. Oil spill exposure was characterized using survey items about economic and physical exposures. Outcomes were depressive symptoms and mental distress.
After adjustment for relevant demographics, depressive symptoms increased over 2 time points following the DHOS, whereas symptoms of mental distress decreased. For every year increase in time since the DHOS, the rate ratio for depressive symptoms increased by a factor of 1.08. In contrast, the rate ratio for mental distress decreased by a factor of 0.97. In addition, initial associations between economic and physical exposure to the DHOS persisted up to 6 years after the spill; women who were more highly exposed experienced higher levels of depressive symptoms (rate ratios ranged from 1.08 to 1.11) and mental distress (rate ratios from 1.05 to 1.11) at each time point than women who were less exposed.
A better understanding of recovery patterns following an oil spill can help direct critical mental health response efforts. (Disaster Med Public Health Preparedness. 2019;13:183–190)
RELIGIOUS, GENDERED, AND CULTURAL CONFLICTS abound in Ali and Nino and can be understood through the lens of honor, a foundational phenomenon in nearly every culture. Honor consistently plays a central role in defining the conflict between Ali, an Azerbaijani Muslim youth, and his Christian Georgian future wife, Nino. Their Romeo-and- Juliet love story explores the tensions inherent in these pairings. Honor is part of the conflict not just between two families, but also between complex, ever-changing pairings: male and female, public and private, Muslim and Christian, East and West. The conflicts about honor and shame in Ali and Nino offer a peek at the fluid boundaries between religion, culture, and politics.
Between the Oriental and European norms concerning female and male honor, the story of the two lovers unfolds across European and Middle-Eastern stages, where Muslim Ali must defend his own honor in his Middle-Eastern culture, as well as Christian Nino's honor in both Middle Eastern and Western settings. The honor structures that Ali and Nino encounter are flexible and—despite the apparent differences between East and West, masculine and feminine—do in fact complement one another or overlap at times. Ali and Nino plays with honor systems that at first sight appear contradictory, mostly by focusing on the Azerbaijani (Muslim, Oriental) honor system, but with instances where Western honor (Christian, Occidental) is thematized as well, demonstrating that honor codes in Azerbaijan mirror the country's political and geographical situation. Parallel to the political situation, the individual female body possesses a certain geography; it can be placed within a larger social constellation and be “mapped” within a certain geography in the novel and can be placed within a larger constellation. We see this in both Nino's relations with other men and the tensions between the country Azerbaijan (easily thought of as feminine) and other, larger forces that claim the country (and its riches) as their own.
Eastern Communitarianism vs. Western Political Liberalism
Ali and Nino offers Western readers a glimpse of Eastern culture. Kurban Said wrote a text positioned between cultures, and we must keep in mind that he is interested in how social and cultural systems interact with each other. Ali's culture and honor codes are perceived within a communitarian system, in which a communitarian identity dominates all others.
Toxoplasma gondii, a zoonotic parasite of global importance, infects all endothermic vertebrates, with extensive health implications. The prevalence of this parasite is seldom monitored in wildlife. Here, a semi-aquatic species, the Eurasian otter (Lutra lutra) was used as a model to assess the potential effect of climate, land cover and biotic factors on T. gondii seroprevalence in British wildlife. The Sabin–Feldman cytoplasm-modifying dye test identified T. gondii antibodies in 25·5% of blood samples from otters found dead, mainly as road kill, in England and Wales, between 2004 and 2010. Otters in the east of England were more likely to be infected with T. gondii than those in western regions. Land cover and temperature are key determinants of T. gondii infection risk, with more infection in arable areas and lower infection where temperatures are higher. The probability of T. gondii infection increased with host age, reflecting cumulative exposure with time, but there was no association between T. gondii seroprevalence and cause of host death.
In a preface to the first of the six volumes of domestic tours he published between 1798 and 1800 as The British Tourists; or Traveller's Pocket Companion, WilBritain's home territories comparatively little known:
It was long a reflection on the natiliam Fordyce Mavor began with a dry comment on the fact that the status and popularity of the Grand Tour had left onal taste and judgment, that our people of fashion knew something, from ocular demonstration, of the general appearance of every country in Europe, except their own.
This was a commonly held view in the period, but for a Scottish Whig like Mavor, the point was that the outstanding features of modern Britain were all on show in the home tour. ‘[I] n whatever light we regard the British Islands;’ he observed:
whether as the cradle of liberty, the mother of arts and sciences, the nurse of manufactures, the mistress of the sea; or whether we contemplate their genial soil, their mild climate, their various natural and artificial curiosities, we shall find no equal extent of territory, on the face of the globe, of more importance, or containing more attractions […]. (v– vi)
The project Mavor was introducing was his selection of the domestic tours published in the last third of the eighteenth century, which, at least on his terms, displayed the genre at its best. This work was, he stated, oriented towards patriotism and benevolence, framed in terms of ‘utility and propriety’ as a contribution to ‘to the public good’ (viii). The excerpted, collected tours were intended to detail British improvement and advancement – subjects that Mavor, who was from a modest background, was keen should circulate to the widest possible audience. Modern tours were, he noted, the preserve of the wealthy due to their cost, but he optimistically imagined The British Tourists as a way of putting them ‘within the reach of every class of his fellow subjects’ (ix). In tandem with the levelling sentiment of this comment, the project was one of enlightenment and education, and Mavor used metaphors of illumination to say more about the public benefit of collecting and abridging tours.
Despite more than 100 years of research, there is no agreement among experts as to whether or not primates can imitate. Part of the problem is that there is little agreement as to what constitutes an example of “imitation.” Nevertheless, recent research provides compelling evidence for both continuities and discontinuities in the psychological faculty that mediates imitation performance. A number of studies have shown that monkeys and apes are capable of copying familiar responses, but it is questionable whether they can also copy novel responses, particularly those involving novel tool-related actions. These results have been interpreted to mean that primates cannot engage in “imitation learning” or novel imitation. Yet there is some evidence showing that monkeys can imitate novel “cognitive” rules (i.e., ordinal rules of the form Apple-Boy-Cat) independently of copying specific motor responses. Rather than suggesting that monkeys and other primates are poor imitators, these results suggest that primates can learn novel cognitive rules but not novel motor rules, possibly because such skills require derived neural specializations in the Parietal Lobe linking social and physical cognitive skills. If true, such evidence represents an important discontinuity between the imitation skills of human and non-human primates with significant implications for human cognitive evolution.