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Requests by patients for providers of specific demographic backgrounds pose an ongoing challenge for hospitals, policymakers, and ethicists. These requests may stem from a wide variety of motivations; some may be consistent with broader societal values, although many others may reflect prejudices inconsistent with justice, equity, and decency. This paper proposes a taxonomy designed to assist healthcare institutions in addressing such cases in a consistent and equitable manner. The paper then reviews a range of ethical and logistical challenges raised by such requests and proposed guidance to consider when reviewing and responding to them.
The causal impacts of recreational cannabis legalization are not well understood due to the number of potential confounds. We sought to quantify possible causal effects of recreational cannabis legalization on substance use, substance use disorder, and psychosocial functioning, and whether vulnerable individuals are more susceptible to the effects of cannabis legalization than others.
We used a longitudinal, co-twin control design in 4043 twins (N = 240 pairs discordant on residence), first assessed in adolescence and now age 24–49, currently residing in states with different cannabis policies (40% resided in a recreationally legal state). We tested the effect of legalization on outcomes of interest and whether legalization interacts with established vulnerability factors (age, sex, or externalizing psychopathology).
In the co-twin control design accounting for earlier cannabis frequency and alcohol use disorder (AUD) symptoms respectively, the twin living in a recreational state used cannabis on average more often (βw = 0.11, p = 1.3 × 10−3), and had fewer AUD symptoms (βw = −0.11, p = 6.7 × 10−3) than their co-twin living in an non-recreational state. Cannabis legalization was associated with no other adverse outcome in the co-twin design, including cannabis use disorder. No risk factor significantly interacted with legalization status to predict any outcome.
Recreational legalization was associated with increased cannabis use and decreased AUD symptoms but was not associated with other maladaptations. These effects were maintained within twin pairs discordant for residence. Moreover, vulnerabilities to cannabis use were not exacerbated by the legal cannabis environment. Future research may investigate causal links between cannabis consumption and outcomes.
Decades of research show that (i) social value orientation (SVO) is related to important behavioral outcomes such as cooperation and charitable giving, and (ii) individuals differ in terms of SVO. A prominent scale to measure SVO is the social value orientation slider measure (SVOSM). The central premise is that SVOSM captures a stable trait. But it is unknown how reliable the SVOSM is over repeated measurements more than one week apart. To fill this knowledge gap, we followed a sample of N = 495 over 6 months with monthly SVO measurements. We find that continuous SVO scores are similarly distributed (Anderson-Darling k-sample p = 0.57) and highly correlated (r ≥ 0.66) across waves. The intra-class correlation coefficient of 0.78 attests to a high test-retest reliability. Using multilevel modeling and multiple visualizations, we furthermore find that one’s prior SVO score is highly indicative of SVO in future waves, suggesting that the slider measure consistently captures one’s SVO. Our analyses validate the slider measure as a reliable SVO scale.
Interrupted time-series graphs are often judged by eye. Such a graph might show, for example, patient symptom severity (y) on each of several days (x) before and after a treatment was implemented (interruption). Such graphs might be prone to systematic misjudgment because of serial dependence, where random error at each timepoint persists into later timepoints. An earlier study (Matyas & Greenwood, 1990) showed evidence of systematic misjudgment, but that study has often been discounted due to methodological concerns. We address these concerns and others in two experiments. In both experiments, serial dependence increased mistaken judgments that the interrupting event led to a change in the outcome, though the pattern of results was less extreme than in previous work. Receiver operating characteristics suggested that serial dependence both decreased discriminability and increased the bias to decide that the interrupting event led to a change. This serial dependence effect appeared despite financial incentives for accuracy, despite feedback training, and even in participants who had graduate training relevant to the task. Serial dependence could cause random error to be misattributed to real change, thereby leading to judgments that interventions are effective even when they are not.
Clinicians are often called upon to assess the capacity of a patient to appoint a healthcare agent. Although a consensus has emerged that the standard for such assessment should differ from that for capacity to render specific healthcare decisions, exactly what standard should be employed remains unsettled and differs by jurisdiction. The current models in use draw heavily upon analogous methods used in clinical assessment, such as the “four skills” approach. This essay proposes an alternative model that relies upon categorization and sliding scale risk assessment that can be used to determine to how much scrutiny the proxy appointment should be subjected and how much certainty of accuracy should be required in order to maximize the patient’s autonomy and ensure that her underlying wishes are met.
The Trump presidency generated concern about democratic backsliding and renewed interest in measuring the national democratic performance of the United States. However, the US has a decentralized form of federalism that administers democratic institutions at the state level. Using 51 indicators of electoral democracy from 2000 to 2018, I develop a measure of subnational democratic performance, the State Democracy Index. I then test theories of democratic expansion and backsliding based in party competition, polarization, demographic change, and the group interests of national party coalitions. Difference-in-differences results suggest a minimal role for all factors except Republican control of state government, which dramatically reduces states’ democratic performance during this period. This result calls into question theories focused on changes within states. The racial, geographic, and economic incentives of groups in national party coalitions may instead determine the health of democracy in the states.
The purpose of this investigation was to expand upon the limited existing research examining the test–retest reliability, cross-sectional validity and longitudinal validity of a sample of bioelectrical impedance analysis (BIA) devices as compared with a laboratory four-compartment (4C) model. Seventy-three healthy participants aged 19–50 years were assessed by each of fifteen BIA devices, with resulting body fat percentage estimates compared with a 4C model utilising air displacement plethysmography, dual-energy X-ray absorptiometry and bioimpedance spectroscopy. A subset of thirty-seven participants returned for a second visit 12–16 weeks later and were included in an analysis of longitudinal validity. The sample of devices included fourteen consumer-grade and one research-grade model in a variety of configurations: hand-to-hand, foot-to-foot and bilateral hand-to-foot (octapolar). BIA devices demonstrated high reliability, with precision error ranging from 0·0 to 0·49 %. Cross-sectional validity varied, with constant error relative to the 4C model ranging from −3·5 (sd 4·1) % to 11·7 (sd 4·7) %, standard error of the estimate values of 3·1–7·5 % and Lin’s concordance correlation coefficients (CCC) of 0·48–0·94. For longitudinal validity, constant error ranged from −0·4 (sd 2·1) % to 1·3 (sd 2·7) %, with standard error of the estimate values of 1·7–2·6 % and Lin’s CCC of 0·37–0·78. While performance varied widely across the sample investigated, select models of BIA devices (particularly octapolar and select foot-to-foot devices) may hold potential utility for the tracking of body composition over time, particularly in contexts in which the purchase or use of a research-grade device is infeasible.
The advent of modern, high-speed electron detectors has made the collection of multidimensional hyperspectral transmission electron microscopy datasets, such as 4D-STEM, a routine. However, many microscopists find such experiments daunting since analysis, collection, long-term storage, and networking of such datasets remain challenging. Some common issues are their large and unwieldy size that often are several gigabytes, non-standardized data analysis routines, and a lack of clarity about the computing and network resources needed to utilize the electron microscope. The existing computing and networking bottlenecks introduce significant penalties in each step of these experiments, and thus, real-time analysis-driven automated experimentation for multidimensional TEM is challenging. One solution is to integrate microscopy with edge computing, where moderately powerful computational hardware performs the preliminary analysis before handing off the heavier computation to high-performance computing (HPC) systems. Here we trace the roots of computation in modern electron microscopy, demonstrate deep learning experiments running on an edge system, and discuss the networking requirements for tying together microscopes, edge computers, and HPC systems.
Loss of empathy is a hallmark feature of behavioral variant frontotemporal dementia (bvFTD). Change in socioemotional functioning identified by others is often the primary initial presenting concern in this disorder, in contrast to more subtle early cognitive changes and limited patient insight. The present study examined the predictive utility of an empathy informant-report measure for discriminating clinician-diagnosed bvFTD from other dementia syndromes.
Data from the National Alzheimer’s Coordinating Center (NACC) database were used to study individuals with bvFTD (n = 406) and other dementia syndromes (n = 385). Participants were administered neuropsychological measures and collateral informants completed an informant-report of empathy.
Informants reported that patients with bvFTD demonstrated significantly lower levels of empathic concern [F(1, 789) = 120.91, p < .001, η2 = 0.13] and perspective taking [F(1, 789) = 153.08, p < .001, η2 = 0.16] than patients with other dementia syndromes. These differences were not attributable to the level of global cognitive impairment. Empathy scores were not significantly associated with any neurocognitive measure when controlling for age. ROC curve analyses showed fair to good clinical utility of the informant-report empathy measure for distinguishing bvFTD from non-bvFTD, whereas a traditional measure of executive functioning failed to differentiate the groups.
These findings indicate that informant ratings of empathy offer a unique source of clinical information that may be useful in detecting neurobehavioral changes specific to bvFTD before a clear neurocognitive pattern emerges on testing.
We conducted a scientific survey of paediatric practitioners who manage heart failure with dilated cardiomyopathy in children. The survey covered management from diagnosis to treatment to monitoring, totalling 63 questions. There were 54 respondents from 40 institutions and 3 countries. There were diverse selections of management options by the respondents in general, but also unanimity in some management options. Variation in practice is likely due to the relative paucity of scientific data in this field and lack of strong evidence-based recommendations from guidelines, which presents an opportunity for future research and quality improvement efforts as the evidence base continues to grow.
This essay advocates for the wholesale reevaluation of the process used by American medical schools for selecting physicians, examining fundamental questions such as the purpose of physicians and the nature of meritocracy. It raises questions about the size of medical school classes, the specific academic requirements, and the inadequacy of current efforts to increase diversity. Ultimately, the essay argues for consideration of a range of reforms that will focus on the community-empowering aspects of medical admissions decisions.
The Society of Thoracic Surgeons Congenital Heart Surgery Database and the Vermont Oxford Network Expanded Database are both large, international, well-established quality and outcomes databases with high penetration in their respective fields of congenital heart surgery and neonatology. Previous studies have shown the value of combining large databases for research purposes. Our aim was to examine the feasibility and value of combining these databases on a local level.
We included patients from both databases, cared for at our centre and born from 2015–2020, who had cardiac surgery as neonates or during the birth hospitalisation. We examined the number of patients from each database and overlap between the two. We compared cardiac diagnoses, surgeries performed, pre-operative factors, mortality, and length of stay between databases.
Of the 255 patients meeting criteria, 209 (81.9%) had records in both databases. The most common diagnoses in both were hypoplastic left heart syndrome, coarctation, and transposition of the great arteries. Surgical data were incompletely recorded in Vermont Oxford. Gestational age, birth weight, multiple gestation, mortality, and length of stay did not differ significantly between the databases, while the percentage of patients with an extracardiac malformation or genetic syndrome recorded was higher in the Society for Thoracic Surgeons group.
Larger-scale matching and comparison studies using these databases are feasible and desirable; for some variables, a record with data from both databases may be more complete. Specific attention should be given to inclusion criteria, reconciling different schema of diagnoses, and formulating questions relying on each database’s relative strengths.
The goal of this Element is to provide a detailed introduction to adaptive inventories, an approach to making surveys adjust to respondents' answers dynamically. This method can help survey researchers measure important latent traits or attitudes accurately while minimizing the number of questions respondents must answer. The Element provides both a theoretical overview of the method and a suite of tools and tricks for integrating it into the normal survey process. It also provides practical advice and direction on how to calibrate, evaluate, and field adaptive batteries using example batteries that measure variety of latent traits of interest to survey researchers across the social sciences.
To evaluate the effectiveness of ultraviolet-C (UV-C) disinfection as an adjunct to standard chlorine-based disinfectant terminal room cleaning in reducing transmission of hospital-acquired multidrug-resistant organisms (MDROs) from a prior room occupant.
A retrospective cohort study was conducted to compare rates of MDRO transmission by UV-C status from January 1, 2016, through December 31, 2018.
Acute-care, single-patient hospital rooms at 6 hospitals within an academic healthcare system in Pennsylvania.
Transmission of hospital-acquired MDRO infection was assessed in patients subsequently assigned to a single-patient room of a source occupant with carriage of 1 or more MDROs on or during admission. Acquisition of 5 pathogens was compared between exposed patients in rooms with standard-of-care chlorine-based disinfectant terminal cleaning with or without adjunct UV-C disinfection. Logistic regression analysis was used to estimate the adjusted risk of pathogen transfer with adjunctive use of UV-C disinfection.
In total, 33,771 exposed patient admissions were evaluated; the source occupants carried 46,688 unique pathogens. Prior to the 33,771 patient admissions, 5,802 rooms (17.2%) were treated with adjunct UV-C disinfection. After adjustment for covariates, exposed patients in rooms treated with adjunct UV-C were at comparable risk of transfer of any pathogen (odds ratio, 1.06; 95% CI, 0.84–1.32; P = .64).
Our analysis does not support the use of UV-C in addition to post-discharge cleaning with chlorine-based disinfectant to lower the risk of prior room occupant pathogen transfer.
Subthreshold/attenuated syndromes are established precursors of full-threshold mood and psychotic disorders. Less is known about the individual symptoms that may precede the development of subthreshold syndromes and associated social/functional outcomes among emerging adults.
We modeled two dynamic Bayesian networks (DBN) to investigate associations among self-rated phenomenology and personal/lifestyle factors (role impairment, low social support, and alcohol and substance use) across the 19Up and 25Up waves of the Brisbane Longitudinal Twin Study. We examined whether symptoms and personal/lifestyle factors at 19Up were associated with (a) themselves or different items at 25Up, and (b) onset of a depression-like, hypo-manic-like, or psychotic-like subthreshold syndrome (STS) at 25Up.
The first DBN identified 11 items that when endorsed at 19Up were more likely to be reendorsed at 25Up (e.g., hypersomnia, impaired concentration, impaired sleep quality) and seven items that when endorsed at 19Up were associated with different items being endorsed at 25Up (e.g., earlier fatigue and later role impairment; earlier anergia and later somatic pain). In the second DBN, no arcs met our a priori threshold for inclusion. In an exploratory model with no threshold, >20 items at 19Up were associated with progression to an STS at 25Up (with lower statistical confidence); the top five arcs were: feeling threatened by others and a later psychotic-like STS; increased activity and a later hypo-manic-like STS; and anergia, impaired sleep quality, and/or hypersomnia and a later depression-like STS.
These probabilistic models identify symptoms and personal/lifestyle factors that might prove useful targets for indicated preventative strategies.