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Mental health policy makers require evidence-based information to optimise effective care provision based on local need, but tools are unavailable.
To develop and validate a population-level prediction model for need for early intervention in psychosis (EIP) care for first-episode psychosis (FEP) in England up to 2025, based on epidemiological evidence and demographic projections.
We used Bayesian Poisson regression to model small-area-level variation in FEP incidence for people aged 16–64 years. We compared six candidate models, validated against observed National Health Service FEP data in 2017. Our best-fitting model predicted annual incidence case-loads for EIP services in England up to 2025, for probable FEP, treatment in EIP services, initial assessment by EIP services and referral to EIP services for ‘suspected psychosis’. Forecasts were stratified by gender, age and ethnicity, at national and Clinical Commissioning Group levels.
A model with age, gender, ethnicity, small-area-level deprivation, social fragmentation and regional cannabis use provided best fit to observed new FEP cases at national and Clinical Commissioning Group levels in 2017 (predicted 8112, 95% CI 7623–8597; observed 8038, difference of 74 [0.92%]). By 2025, the model forecasted 11 067 new treated cases per annum (95% CI 10 383–11 740). For every 10 new treated cases, 21 and 23 people would be assessed by and referred to EIP services for suspected psychosis, respectively.
Our evidence-based methodology provides an accurate, validated tool to inform clinical provision of EIP services about future population need for care, based on local variation of major social determinants of psychosis.
A previously healthy 42-year-old male developed a fever and cough shortly after returning to Canada from overseas. Initially, he had mild upper respiratory tract infection symptoms and a cough. He was aware of the coronavirus disease-2019 (COVID-19) and the advisory to self-isolate and did so; however, he developed increasing respiratory distress over several days and called 911. On arrival at the emergency department (ED), his heart rate was 130 beats/min, respiratory rate 32 per/min, and oxygenation saturation 82% on room air. As per emergency medical services (EMS) protocol, they placed him on nasal prongs under a surgical mask at 5 L/min and his oxygen saturation improved to 86%.
Shanidar Cave in Iraqi Kurdistan became an iconic Palaeolithic site following Ralph Solecki's mid twentieth-century discovery of Neanderthal remains. Solecki argued that some of these individuals had died in rockfalls and—controversially—that others were interred with formal burial rites, including one with flowers. Recent excavations have revealed the articulated upper body of an adult Neanderthal located close to the ‘flower burial’ location—the first articulated Neanderthal discovered in over 25 years. Stratigraphic evidence suggests that the individual was intentionally buried. This new find offers the rare opportunity to investigate Neanderthal mortuary practices utilising modern archaeological techniques.
The hostile environment that older lesbian, gay, bisexual and transgender (LGBT) people faced at younger ages in the United Kingdom (UK) may have a lasting negative impact on their health. This systematic scoping review adds to the current knowledge base through comprehensively synthesising evidence on what is known about the extent and nature of health and care inequalities, as well as highlighting gaps in the evidence which point the way towards future research priorities. We searched four databases, undertook manual searching, and included studies which presented empirical findings on LGBT people aged 50+ in the UK and their physical and mental health or social care status. From a total of 5,738 records, 48 papers from 42 studies were eligible and included for data extraction. The synthesis finds that inequities exist across physical and mental health, as well as in social care, exposure to violence and loneliness. Social care environments appeared as a focal point for inequities and formal care environments severely compromised the identity and relationships that older LGBT people developed over their lifecourse. Conversely, the literature demonstrated how some older LGBT people successfully negotiated age-related transitions, e.g. emphasising the important role of LGBT-focused social groups in offsetting social isolation and loneliness. While there exist clear policy implications around the requirement for formal care environments to change to accommodate an increasingly diverse older population, there is also a need to explore how to support older LGBT people to maintain their independence for longer, reducing the need for formal care.
Point-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED).
We completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.
POCUS was performed on 180 patients; 45 patients (25.0%; 19.2%–31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%–17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%–33.0%) achieved ROSC, 18 (10.0%; 6.3%–15.3%) survived to admission, and 3 (1.7%; 0.3%–5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%–88.7%) and a specificity of 46.8% (32.1%–61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%–98.8%) but a similar specificity of 34.0% (20.9%–49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%–99.78%) and a specificity of 16.00% (4.54%–36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%–97.22%) and a specificity of 54.55% (32.21%–75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0–4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge.
The absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.
Field identification of ST-elevation myocardial infarction (STEMI) and advanced hospital notification decreases first-medical-contact-to-balloon (FMC2B) time. A recent study in this system found that electrocardiogram (ECG) transmission following a STEMI alert was frequently unsuccessful.
Instituting weekly test ECG transmissions from paramedic units to the hospital would increase successful transmission of ECGs and decrease FMC2B and door-to-balloon (D2B) times.
This was a natural experiment of consecutive patients with field-identified STEMI transported to a single percutaneous coronary intervention (PCI)-capable hospital in a regional STEMI system before and after implementation of scheduled test ECG transmissions. In November 2014, paramedic units began weekly test transmissions. The mobile intensive care nurse (MICN) confirmed the transmission, or if not received, contacted the paramedic unit and the department’s nurse educator to identify and resolve the problem. Per system-wide protocol, paramedics transmit all ECGs with interpretation of STEMI. Receiving hospitals submit patient data to a single registry as part of ongoing system quality improvement. The frequency of successful ECG transmission and time to intervention (FMC2B and D2B times) in the 18 months following implementation was compared to the 10 months prior. Post-implementation, the time the ECG transmission was received was also collected to determine the transmission gap time (time from ECG acquisition to ECG transmission received) and the advanced notification time (time from ECG transmission received to patient arrival).
There were 388 patients with field ECG interpretations of STEMI, 131 pre-intervention and 257 post-intervention. The frequency of successful transmission post-intervention was 73% compared to 64% prior; risk difference (RD)=9%; 95% CI, 1-18%. In the post-intervention period, the median FMC2B time was 79 minutes (inter-quartile range [IQR]=68-102) versus 86 minutes (IQR=71-108) pre-intervention (P=.3) and the median D2B time was 59 minutes (IQR=44-74) versus 60 minutes (IQR=53-88) pre-intervention (P=.2). The median transmission gap was three minutes (IQR=1-8) and median advanced notification time was 16 minutes (IQR=10-25).
Implementation of weekly test ECG transmissions was associated with improvement in successful real-time transmissions from field to hospital, which provided a median advanced notification time of 16 minutes, but no decrease in FMC2B or D2B times.
While the use of formal trauma teams is widely promoted, the literature is not clear that this structure provides improved outcomes over emergency physician delivered trauma care. The goal of this investigation was to examine if a trauma team model with a formalized, specialty-based trauma team, with specific activation criteria and staff composition, performs differently than an emergency physician delivered model. Our primary outcome was survival to discharge or 30 days.
An observational registry-based study using aggregate data from both the New Brunswick and Nova Scotia trauma registries was performed with data from April 1, 2011 to March 31, 2013. Inclusion criteria included patients 16 years-old and older who had an Injury Severity Score greater than 12, who suffered a kinetic injury and arrived with signs of life to a level-1 trauma centre.
266 patients from the trauma team model and 111 from the emergency physician model were compared. No difference was found in the primary outcome of proportion of survival to discharge or 30 days between the two systems (0.88, n=266 vs. 0.89, n=111; p=0.8608).
We were unable to detect any difference in survival between a trauma team and an emergency physician delivered model.
The emergency department (ED) left-without-being-seen (LWBS) rate is a performance indicator, although there is limited knowledge about why people leave, or whether they seek alternate care. We studied characteristics of ED LWBS patients to determine factors associated with LWBS.
We collected demographic data on LWBS patients at two urban hospitals. Sequential LWBS patients were contacted and surveyed using a standardized telephone survey. A matched group of patients who did not leave were also surveyed. Data were analysed using the Fisher exact test, chi-square test, and student t-test.
The LWBS group (n=1508) and control group (n=1504) were matched for sex, triage category, recorded wait times, employment and education, and having a family physician. LWBS patients were younger, more likely to present in the evening or at night, and lived closer to the hospital. A long wait time was the most cited reason for leaving (79%); concern about medical condition was the most common reason for staying (96%). Top responses for improved likelihood of waiting were shorter wait times (LWBS, 66%; control, 31%) and more information on wait times (41%; 23%). A majority in both groups felt that their condition was a true emergency (63%; 72%). LWBS patients were more likely to seek further health care (63% v. 28%; p<0.001) and sooner (median time 1 day v. 2-4 days; p=0.002). Among patients who felt that their condition was not a true emergency, the top reason for ED attendance was the inability to see their family doctor (62% in both groups).
LWBS patients had similar opinions, experiences, and expectations as control patients. The main reason for LWBS was waiting longer than expected. LWBS patients were more likely to seek further health care, and did so sooner. Patients wait because of concern about their health problem. Shorter wait times and improved communication may reduce the LWBS rate.
Many jurisdictions in the USA and globally are considering raising the prices of sugar-sweetened beverages (SSB) through taxes as a strategy to reduce their consumption. The objective of the present study was to identify whether the rationale provided for an SSB price increase affects young adults’ behavioural intentions and attitudes towards SSB.
Participants were randomly assigned to receive one of eight SSB price increase rationales. Intentions to purchase SSB and attitudes about the product and policy were measured.
A forty-six-item cross-sectional Internet survey.
Undergraduate students (n 494) at a large US Midwestern university.
Rationale type was significantly associated with differences in participants’ purchasing intentions for the full sample (F7,485=2·53, P=0·014). Presenting the rationale for an SSB price increase as a user fee, an effort to reduce obesity, a strategy to offset health-care costs or to protect children led to lower SSB purchasing intentions compared with a message with no rationale. Rationale type was also significantly associated with differences in perceptions of soda companies (F7,485=2·10, P=0·043); among low consumers of SSB, messages describing the price increase as a user fee or tax led to more negative perceptions of soda companies.
The rationale attached to an SSB price increase could influence consumers. However, these message effects may depend on individuals’ level of SSB consumption.
The Elements of Crimes, an example of one of the Rome Statute system's many innovative contributions to international criminal law, were adopted by the Preparatory Commission (PrepComm) for crimes of genocide, crimes against humanity and war crimes on 30 June 2000, and then by the Assembly of States Parties on 9 September 2002.
Elements of Crimes form an important part of the range of instruments available to the Court. They elaborate the definitions of the Rome Statute crimes and thereby assist the Court in their interpretation and application, including, upon entry into force of the relevant amendments, the crime of aggression. The Elements of Crimes must be read in conjunction with article 30 of the Rome Statute, which sets out the general rules with respect to the ‘mental element’ of each crime, i.e. personal criminal liability and responsibility shall only accrue if the ‘material elements’ of the relevant crime are committed with intent and knowledge.
Although the PrepComm was mandated by Resolution F of the Final Act of the Rome Conference to prepare proposals on the crime of aggression including the elements,5negotiations on the elements of the crime of aggression (hereafter ‘the Elements’) were slow to commence in earnest, both in the PrepComm and in the Special Working Group on the Crime of Aggression (Special Working Group) that took over its mandate. That said, this chapter will illustrate how discussions on the Elements in the context of informal settings and formal meetings of the Assembly of States Parties progressed rapidly and effectively once the Special Working Group had agreed on a draft definition of the crime of aggression in February 2009.
The European Union's (EU) interest and involvement in foreign direct investment (FDI) is by no means new. However, it has only been comparatively recently that one has been able to begin to distinguish the particularities of a specific EU approach to FDI, especially when placed within a broader developmental context. The approach has been most visible during the ongoing negotiations of Economic Partnership Agreements (EPAs) with the African, Caribbean and Pacific (ACP) grouping of States. Though the EU–ACP relationship is often promoted (by the EU) as a model of mutual and benign co-operation between economically divergent States, the relationship highlights, in fact, political and normative challenges for both sides. In particular, whereas the EU has sought to utilise its links with the ACP countries to fashion a uniquely global role for itself, practice suggests this relationship is much more problematic for both. And what has in the past proved true for trade, is proving equally true in relation to FDI.
This chapter seeks to critically address the role of the EU as a global investment actor, with particular focus on the supposed synergies between FDI as a development assistance tool and FDI as a means to promote market liberalisation. This is especially significant as the entry into force of the Treaty of Lisbon in December 2009 has, for the first time, introduced the first explicit reference to foreign investment in the EU's treaty arrangements. While the grant of competence to the EU in this area will provide a clearer mandate for action, it fails to resolve the overarching question as to its purpose. The chapter thus focuses on one particular aspect of this broader debate, namely, the negotiation of investment provisions within EPAs, with particular comment on the investment provisions of the 2008 EPA negotiated between the EU and the Caribbean States. In devising the rules on investment, the final text is innovative in numerous respects, though whether the investment liberalisation attained will also provide the stated developmental benefits is more contested. The chapter concludes by noting the unique range of pressures exerted on the EU in framing co-ordinated policies in the areas of FDI and development; thus, while the EU's rhetoric is often extremely positive on such issues, its capacity to implement them – and implement them fully and in an integrated manner – is invariably subject to the risk of incoherence and fragmentation.
In 1998 a circle of timber posts within the intertidal zone on the north Norfolk coast was brought to the attention of the Norfolk County Council Archaeological Service. A subsequent programme of archaeological recording and dating revealed that the structure was constructed in the spring or early summer of 2049 BC, during the Early Bronze Age. Because of the perceived threat of damage and erosion from the sea a rescue excavation was undertaken during the summer months of 1999. The structure was entirely excavated, involving the removal of the timbers and a programme of stratigraphic recording and environmental analysis. A survey was also undertaken within the environs of the site which has identified further timber structures dating from the Bronze Age. Detailed examination of the timber from the circle has produced a wealth of unexpected information which has added greatly to our understanding of Early Bronze Age woodworking, organisation of labour and the layout and construction of timber ritual monuments.
We examine, from the partial structures perspective, two forms of applicability of mathematics: at the “bottom” level, the applicability of theoretical structures to the “appearances”, and at the “top” level, the applicability of mathematical to physical theories. We argue that, to accommodate these two forms of applicability, the partial structures approach needs to be extended to include a notion of “partial homomorphism”. As a case study, we present London's analysis of the superfluid behavior of liquid helium in terms of Bose-Einstein statistics. This involved both the introduction of group theory at the top level, and some modeling at the “phenomenological” level, and thus provides a nice example of the relationships we are interested in. We conclude with a discussion of the “autonomy” of London's model.
Preterm birth remains a paramount problem in health care worldwide. In the USA, approximately 6–10% of births occur preterm.1–3 Gestational age at birth is the most important determinant of an infant's morbidity and mortality. Preterm infants account for approximately 75% of neonatal deaths,3–5 as well as incalculable direct and indirect financial costs and morbidity.6–9
This paper is divided into three sections. §1 consists of an argument against the validity of Berry's paradox; §2 consists of supporting arguments for the thesis presented in §1; and §3 examines the possibility of re-establishing the paradox.
Berry's paradox, a semantic antinomy, is described on p. 4 of the textbook  as follows:
For the sake of argument, let us admit that all the words of the English language are listed in some standard dictionary. Let T be the set of all thenatural numbers that can be described in fewer than twenty words of the English language. Since there are only a finite number of English words, there are only finitely many combinations of fewer than twenty such words—that is, T is a finite set. Quite obviously, then, there are natural numbers which are greater than all the elements of T; hence there is a least natural number which cannot be described in fewer than twenty words of the English language. By definition, this number is not in T; yet we have described it in sixteen words, hence it is in T.
We are faced with a glaring contradiction; since the above argument would be unimpeachable if we admitted the existence of the set T, we are irrevocably led to the conclusion that a set such as T simply cannot exist.