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During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient’s lifetime.
Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis.
The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (−$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care.
Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient’s lifetime.
IAU Commission 29 - Stellar Spectra has been one of the IAU commissions from the onset, until its dissolution at the most recent IAU General Assembly in Honolulu in 2015. This commission belonged to IAU Division G (“Stars and Stellar Physics”), the latter committed with fostering research in stellar astrophysics. Within the general field of stellar astrophysics, stellar spectroscopy plays a key role, as stellar spectra are a powerful tool providing a view into the detailed physical properties of stars and the physical processes occuring within them.
Brain tumors have been loosely divided between primary (occurring from the cells native to the CNS) and secondary or metastatic (from spread by direct contiguous contact or hematologic spread). The incidence of primary brain tumors in the USA is roughly 6.4 for every 100,000 people, with the majority comprising the glioblastoma subtype. Metastatic brain tumors occur in 15–20% of all cancer patients with the primary etiology being lung, breast, melanoma, and renal tumors. With the development of new imaging techniques, innovative surgical techniques, and progressive adjunctive therapies, the treatment of brain tumors now involves earlier diagnosis, improved accuracy for surgery, and more medical and radiation options for patients with brain tumors. Despite improved imaging techniques that can better describe the characteristics of brain tumors without tissue evaluation, the role of craniotomy surgery is an important component of both diagnosis and treatment of patients with brain tumors. As opposed to formal craniotomy, stereotactic needle biopsy can be used for those patients with tumor in a deep, functionally important region of the brain and in patients with poor systemic health. Histologic examination of these core needle biopsies is then used to direct therapy. Craniotomy and surgical debulking/excision are especially beneficial in those patients with large lesions that are symptomatic due to size and edema that cause compression of surrounding brain tissue.
Preoperative imaging for brain tumors is technically specific to each individual patient. With expert interpretation, surgical planning can be made with a general understanding of the goal of the procedure. Imaging techniques have progressed to include digital subtraction angiography, MRI, MR spectroscopy and functional MRI, to name a few. These techniques provide valuable information, but are frequently unable to exclude all other non-tumorous lesions like infarction, infection, and multiple sclerosis. Thus a craniotomy or needle biopsy is required to obtain definitive diagnosis.
The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.
(Disaster Med Public Health Preparedness. 2011;5:S20-S31)
Ken Hill has been living with the ghost of a nine-year-old Nova Scotia boy for over eighteen years. Hill can picture Andrew Warburton as he was on a sunny day in July 1986 when he was enjoying activities near his aunt's rural home. Dressed in swimming trunks, a tank top, and sneakers, he independently set off to meet his older brother at a lake several hundred meters from the house. Although he had previously walked the path with playmates, Andrew disappeared in the forest on his way to the lake. A massive search effort resulted, ultimately involving over 5,000 community volunteers, fire fighters, and military personnel. The police search manager called the nearby university and asked for a psychologist who knew anything about children's spatial behaviour. Professor Ken Hill agreed to meet the search manager at the incident command post. Hill was asked to indicate on a map of the surrounding environment where search efforts should be focused. Hill remembers that he could think of nothing in the sizable literature on the development of children's spatial representation that applied to this problem. It was obvious that Hill had little to offer, and as the co-ordinators of the search continued to converse among themselves, Hill slipped away from the post to join one of the ground search teams. After eight days of the search effort, Andrew Warburton was found dead from hypothermia, approximately 3.2 km from the place where he had last been seen.
Despite the large numbers of displaced persons and the often-lengthy periods of displacement, little is known about the impact of forced migration on long-term under-five mortality. This paper looks at the Brass Method (and adaptations of this method) and the Preceding Birth Technique in combination with a classification of women by their migration and reproductive histories, in order to study the impact of forced migration on under-five mortality. Data came from the Demography of Forced Migration Project, a study on mortality, fertility and violence in the refugee and host populations of Arua District, Uganda and Yei River District, Sudan. Results indicate that women who did not migrate in a situation of conflict and women who repatriated before the age of 15, had children with the highest under-five mortality rates compared with women who were currently refugees and women who repatriated after the age of 15.
Peter Trudgill & Jean Hannah, International
English: A guide to varieties of Standard English. 4th ed. London:
Arnold; New York: Oxford University Press, 2002. Pp. i–xv,
1–153. Pb $22.95.
This book provides a delightful survey of the global variety of
pronunciation and usage of English as an educated standard. It focuses
on the phonetics of the various Englishes, especially on the vowels,
where so much of the variability resides, and on differences in usage,
lexical and syntactic as well as orthographic. Although this small
volume necessarily deals with most topics briefly, it includes a wealth
Child mortality (the mortality of children less than five years old) declined considerably in the developing world in the 1990s, but infant mortality declined less. The reductions in neonatal mortality were not impressive and, as a consequence, there is an increasing percentage of infant deaths in the neonatal period. Any further reduction in child mortality, therefore, requires an understanding of the determinants of neonatal mortality. 209,628 birth and 2581 neonatal death records for the 1998 birth cohort from the city of São Paulo, Brazil, were probabilistically matched. Data were from SINASC and SIM, Information Systems on Live Births and Deaths of Brazil. Logistic regression was used to find the association between neonatal mortality and the following risk factors: birth weight, gestational age, Apgar scores at 1 and 5 minutes, delivery mode, plurality, sex, maternal education, maternal age, number of prior losses, prenatal care, race, parity and community development. Infants of older mothers were less likely to die in the neonatal period. Caesarean delivery was not found to be associated with neonatal mortality. Low birth weight, pre-term birth and low Apgar scores were associated with neonatal death. Having a mother who lives in the highest developed community decreased the odds of neonatal death, suggesting that factors not measured in this study are behind such association. This result may also indicate that other factors over and above biological and more proximate factors could affect neonatal death.
Provision of services for older people is now a priority for policy makers, not least because of population aging precipitating a ‘demographic revolution’. In England, one response by policy-makers has been a National Service Framework, designed to provide standards and models for the care of older people. Furthermore, recent moves to create strategic partnership agreements between the Department of Health, the NHS and the Voluntary and Community Sector point to increasing awareness of the interconnections between health and social care. However, even when services are in place, older people do not always use them. Understanding why this might be the case is key to further service planning and implementation.
In complex emergencies, especially those involving famine and/or wide-spread food insecurity, assessments of malnutrition are critical to understanding the population's health status and to assessing the effectiveness of relief interventions. Although the Democratic People's Republic of Korea (DPRK) has benefited from some of the largest, most sustained appeals in the history of the World Food Program (WFP), the government in Pyongyang has placed restrictions on international efforts to gather data on the health and nutritional status of the affected population.
Question: Lacking direct means to assess the nutritional status of the North Korean populace, what other methodologies could be employed to measure the public health impacts of chronic food shortage?
The paper begins with a review of methods for assessing nutritional status, particularly in emergencies; a brief history of the North Korean food crisis (1995–2001), and a review of the available nutritional and health data on the DPRK. The main focus of the paper is on the results of a survey of 2,692 North Korean adult migrants in China. Recognizing certain biases and limitations, the study suggests that sample households have experienced an overall decline in food security, as evidenced by both the decline in government rations from an average of 120 grams per person per day to less than 60 grams per day, and by the increase in the percentage of households relying on foraging or bartering of assets as their principal source of food. It also is apparent that the period 1995–1998 has been marked by elevated household mortality, declining fertility, and steadily rising out-migration. Taken together, the signs point toward famine, whether that is defined as a discrete event—that is, as a regional failure in food production or distribution leading to elevated mortality from starvation and associated disease—or as a more complex social process whose sub-states include not only elevated mortality, but declining fertility, eating of alternative ‘famine foods’, transfer of assets, and the uprooting and separation of families.
One of the more consistent characterizations of both American Fundamentalism and other versions of conservative Evangelicalism is that these groups represent authoritarian religious and social systems. Such characterizations are not entirely without some basis in fact. Fundamentalism will almost always appear authoritarian, and so too will forms of Pentecostalism which, like Fundamentalism, place a heavy emphasis on correct thinking and combine a belief in the infallibility of scripture with a commitment to literal readings. Outsiders are sometimes disconcerted to find that “authoritarian” and related concepts are not assessed negatively in conservative Evangelical circles. Quite the contrary is the case: the Bible, infallible, inerrant, “God-breathed,” is the clear center of Evangelical authority. Many a Fundamentalist sermon has sought to clinch its case with the phrase, “on authority of the holy Word of God.”
Computer graphics systems that provide interactive display and manipulation of three-dimensional data are powerful tools for the analysis and communication of technical information required for characterization and design of a geologic repository for nuclear waste. Greater understanding of site performance and repository design information is possible when performance-assessment modeling results can be visually analyzed in relation to site geologic and hydrologic information and engineering data for surface and subsurface facilities. In turn, this enhanced visualization capability provides better communication between technical staff and program management with respect to analysis of available information and prioritization of program planning.
A commercially-available computer system was used to demonstrate some of the current technology for three-dimensional visualization within the architecture of information systems for nuclear waste management. This computer system was used to interactively visualize and analyze the information for two examples: 1) site-characterization and engineering data for a potential geologic repository at Yucca Mountain, Nevada; and 2) three-dimensional simulations of a hypothetical release and transport of contaminants from a source of radionuclides to the vadose zone. Users may assess the three-dimensional distribution of data and modeling results by interactive zooming, rotating, slicing, and peeling operations. For those parts of the database where information is sparse or not available, the software incorporates models for the interpolation and extrapolation of data over the three-dimensional space of interest.
Most studies of contextual influences on political attitudes and behavior have treated geographical areas as the operative social environment. As early research on social influence processes noted, the conditions that promote consensus among inhabitants of a common environment are likely to be present in formal organizations that encourage face-to-face interaction. Churches possess many of the characteristics that should maximize behavioral contagion and are thus fertile ground for the dissemination of common political outlooks. This expectation is tested by assessing the link between theological and political conservatism in 21 Protestant congregations. The theological climate in the churches is found to contribute strongly to the members' political conservatism over and above the personal commitment of respondents to traditional Christian values and a variety of social and attitudinal variables. As churches constitute the single most widespread form of voluntary organizational affiliation in the United States, their potential political impact appears to be considerable.
To date, a number of studies involving the use of bond prices and/or returns have utilized the published prices of trades on the New York and other exchanges. These exchange quotes reflect the odd-lot activities of individual investors and account for only a negligible portion of the trading in listed issues. In contrast, the vast majority of listed corporate trading occurs over-the-counter and involves round-lot trades between institutions. Given differences in market characteristics, odd-lot exchange prices may differ substantially from those in the round-lot institutional market. This study compares exchange quotations from Moody's Bond Record with prices assigned by Merrill Lynch's institutional pricing service and uses each set of prices to calculate return and risk measures. Institutional (Merrill Lynch) bond prices are shown to be systematically greater than exchange (Moody's) prices. In addition, bond returns based on Merrill Lynch prices are shown to yield significantly higher beta and R2 estimates, as well as significantly lower standard deviation and residual risk estimates.
Bulk milk with an apparently high electronic cell count (ECC) was found to have a normal cell count when the latter was determined directly with a microscope or when cell nuclei were counted with a Fossomatic apparatus. Particles in the form of collapsed spheres formed by aggregated casein micelles were found in bulk milk which accounted for the falsely high ECC values. The ECC value agreed with the values obtained by the other methods if the milk was heated to 55 °C for 15 min before fixation. The shape of the particles and the fact that they were only present after the milk had passed through the milking machine suggested that they may be produced as vacuum vacuoles arising from cavitation in the pump.
In Tlaxcala and Puebla, Mexico, Nahuatl is being replaced by Spanish. Economic and social factors, principally a shift from a peripheral agrarian integration in the Mexican economy to integration as a rural proletariat involved in migratory labor, has been accompanied by a shift in language attitudes which has led to a narrowing of the range of functions of Nahuatl to a function primarily as a “language of solidarity.” This narrowing of function and the accompanying development of ethnic self-consciousness and egalitarianism are expressed through the stigmatization of Spanish loan words, other ethnic boundary-marking usages, the narrowing of honorific usage, and the differentiation of Nahuatl from Spanish grammar in noun-number constructions. (Nahuatl, Spanish, language shift, ethnicity.)
Associated with the concept of the nation state and system is a latent threat structure which this article seeks to delineate and to explore empirically. Why do the Japanese perceive the Russians as a serious political threat while discounting the potential military impact of the Chinese? Why did the United States consider the threat to its interests sufficiently grave in Indochina to fight a 10-year war against communism there while virtually ignoring the Castro regime less than 100 miles off the Florida coast ? What combination of German attributes and behaviour convinced France and Britain in the presence of aggresssive capability that they could disregard the threat posed to Czechoslovakia by Hitler in 1938? The latent threat structure of the nation state is neither obvious nor of trivial importance to global security and peace.