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Background: Infections are a frequent cause of hospital (re)admissions for older adults receiving home health care (HHC) in the United States. However, previous investigators have likely underestimated the prevalence of infections leading to hospitalization due to limitations of identifying infections using Outcome and Assessment Information Set (OASIS), the standardized assessment tool mandated for all Medicare-certified HHC agencies. By linking OASIS data with inpatient data from the Medicare Provider Analysis and Review (MedPAR) file, we were able to better quantify infection hospitalization trends and subsequent mortality among HHC patients. Method: After stratification (by census region, ownership, and urban or rural location) and random sampling, our data set consisted of 2,258,113 Medicare beneficiaries who received HHC services between January 1, 2013, and December 31, 2018, from 1,481 Medicare-certified HHC agencies. The 60-day HHC episodes were identified in OASIS. Hospital transfers reported in OASIS were linked with corresponding MedPAR records. Our outcomes of interest were (1) hospitalization with infection present on admission (POA); (2) hospitalization with infection as the primary cause; and (3) 30-day mortality following hospitalization with infection as the primary cause. We identified bacterial (including suspected) infections based on International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 codes in MedPAR. We classified infections by site: respiratory, urinary tract, skin/soft tissue, intravenous catheter-related, and all (including other or unspecified infection site). We also identified sepsis diagnoses. Result: From 2013 through 2018, the percentage of 60-day HHC episodes with 1 or more hospital transfers ranged from 15% to 16%. Approximately half of all HHC patients hospitalized had an infection POA. Over the 6 years studied, infection (any type) was the primary cause of hospitalization in more than a quarter of all transfers (25.86%–27.57%). The percentage of hospitalizations due to sepsis increased from 7.51% in 2013 to 11.49% in 2018, whereas the percentage of hospitalizations due to respiratory, urinary tract, or skin/soft-tissue infections decreased (p <0.001). Thirty-day mortality following a transfer due to infection ranged from 14.14% in 2013 to 14.98% in 2018; mortality rates were highest following transfers caused by sepsis (23.14%-26.51%) and respiratory infections (13.07%-14.27%). Conclusion: HHC is an important source of post-acute care for those aging in place. Our findings demonstrate that infections are a persistent problem in HHC and are associated with substantial 30-day mortality, particularly following hospitalizations caused by sepsis, emphasizing the importance of infection prevention in HHC. Effective policies to promote best practices for infection prevention and control in the home environment are needed to mitigate infection risk.
Background: Infections are common at end-of-life in older nursing-home residents. This often leads to the overuse of antibiotics and burdensome treatments. Improving infection management through palliative care at the end of life has been proposed as a key strategy to reducing inappropriate antibiotic use. Black nursing-home residents tend to reside in poorly performing nursing homes. We examined palliative care services in nursing homes with varying proportions of black residents. Methods: Cross-sectional, nationally representative nursing-home survey data (2017–2018) was combined with the Minimum Data Set 3.0 (nursing-home resident characteristics), the Certification and Survey Provider Enhanced Reporting data (nursing-home facility characteristics), and the Multidimensional Deprivation Index (county-level poverty estimates). The survey included 24 validated items on nursing-home palliative care services, as well as the nursing home’s infection control program and integration of infection management and palliative care (summative score, 0–100). We used nursing-home facility-level multivariate regression to estimate the relationship between proportion of black residents and palliative care scores, before and after controlling for county-level poverty estimates, facility characteristics, and resident characteristics. We categorized proportion of black residents using methods reported in the literature (25%). Results: The mean weighted palliative-care score in our sample of 869 nursing homes (weighted n = 15,020) was 47.7 (SE, 0.70). In unadjusted analyses, nursing homes with higher proportions of black residents provided significantly fewer palliative care services than nursing homes with no black residents, with the greatest differences (P = .027) observed between nursing homes with >25% black residents (mean palliative care score, 43.82; SE, 2.31) versus nursing homes with no black residents (mean palliative care score, 49.47; SE, 1.08). These disparities persisted after adjustment for urbanicity and county-level poverty rates (p < 0.01) but were attenuated after further adjustment for resident and facility level characteristics (p=0.138). Conclusions: Our findings demonstrate that wide variations in nursing-home palliative-care services exist with increased proportions of black residents, even after accounting for community characteristics. Further research is needed to identify and understand the specific community characteristics that play a role in the provision of palliative care services. Palliative care is a method to reduce inappropriate antimicrobial use at the end of life and should be expanded with a focus on nursing homes with higher proportions of black residents.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Terminal Classic circular architecture has been characterized as a “non-Classic” trait stemming from Chontal-Itza groups from the Gulf lowlands who developed a long-distance, circum-peninsular trade route and established their capital city at Chichen Itza in northern Yucatan. Recent investigations of a series of circular shrines proximate to the Caribbean coast in Belize have yielded ceramics and radiocarbon dates that link these buildings to the ninth century, coeval with the early Sotuta phase at Chichen Itza (a.d. 830–900). We present an architectural comparison of circular shrines and map out a network of sites that cluster along the rivers and coast of Belize. We consider two possibilities that may not be mutually exclusive: (1) local elite emulation of northern styles following pilgrimage to Chichen Itza for political accession ceremonies, and, (2) trading diasporas involving small-scale migration of Chontal-Itza merchants along the eastern Caribbean coast.
Background: Social networks may protect depressed elders against suicidal behavior. However, conflict in important relationships may undermine the sense of social support, potentially negating the protective effects. Thus, we investigated the role of chronic interpersonal difficulties and perceived social support in depressed elders with and without suicidal thoughts and attempts.
Methods: 106 individuals aged 60 years and older participated in this cross-sectional, case-control study. They were placed in three groups: suicidal depressed, non-suicidal depressed and non-depressed. Following a detailed clinical characterization, we assessed perceived social support (Interpersonal Support Evaluation List), and chronic interpersonal difficulties (Inventory of Interpersonal Problems). Using general linear models, we explored the relationship between suicidal thoughts/attempts, social support, and chronic interpersonal difficulties. We also examined whether lower perceived social support explained the relationship between chronic interpersonal difficulties and suicidal thoughts/attempts.
Results: Suicidal depressed elders reported the lowest levels of perceived social support (belonging, tangible support, and self-esteem) and higher levels of chronic interpersonal difficulties (struggle against others and interpersonal hostility), compared to both non-suicidal depressed and non-depressed elders. The relationship between chronic interpersonal difficulties and suicidal behavior was partially explained by low perceived social support.
Conclusions: The experience of strong affects, interpersonal struggle, and hostility in relationships may undermine the sense of social support in depressed elders, possibly leading them to contemplate or attempt suicide. Depressed elders with a history of interpersonal difficulties need to be carefully monitored for suicidal behavior.
We think, and we speak our thoughts. Necessarily we speak them, even to ourselves, in some language, either in a so-called natural one – French, English, Hebrew, Greek – or in one of the so-called artificial languages of mathematics or formal logic. Whatever language we choose to speak, or must speak, however, we take ourselves often enough, most often perhaps, to be speaking in it of real things: things “real” in the sense, a sense introduced to philosophy by Descartes, and the source of much enduring intellectual anguish since, of being “outside the mind.”
But are not words themselves creatures of language? Is language itself not a creation of the human mind? If so, what assurance have we that, when we speak, we speak of the furniture of the universe, of Reality itself, rather than merely of the homely, and home-made, furniture of our own minds?
In raising such doubts we envisage the possibility that language, although it may seem the house of the mind, with windows opening on an extramental, extralinguistic world, may in fact be a prison, with none. The image of language as a prison no doubt owes something, historically, to Plato's myth of the Cave. But those immured in the Prison-House of Language, as philosophers since Locke have conceived it, are rather worse off than those chained facing the back wall of Plato's Cave.
This book is the product of a transatlantic cross-fertilisation. The authors found themselves from 1991 onwards members of the same department, at the University of Utah, to which Harrison had moved from a British university (Sussex). At that time, Hanna was nourishing some doubts about various forms of meaning-scepticism, mainly in Quine and Kripke. Harrison had a number of projects on hand, one of which was an absurdly ambitious attempt to rethink the philosophy of language since Frege from the standpoint of an idiosyncratic reinterpretation of Wittgenstein. Some of the component parts of this enterprise, including a series of exegetical studies of middle-period Wittgenstein, had seen or were about to see print, but the project as a whole was, to put it bluntly, stalled, and had been stalled, except on its exegetical front, since the early 1980s. Conversation between us at first revealed some points of contact between our two projects. Then we began to see the possibility of certain large structural moves that would get Harrison's project moving again, in directions that would provide a framework for Hanna's ideas. At first we thought the work might yield a joint paper. Later we realised that it would have to be a series of papers. Finally we resigned ourselves to producing a joint book. By this time so many changes had occurred in each of our minds, stemming from objections or suggestions by the other, that we would have been at a loss to say which of us “owned” which parts of the project.
It has been a commonplace of philosophy since Frege that “the sense of a sentence is determined by its truth-conditions.” But that, as it stands, is a dark utterance. We need for a start to distinguish between the sentence and its sense. A sentence is just a string of words. Different sentential strings may have the same sense: “express,” as is often said, “the same proposition.” Both (some) sentences and the propositions they express may be said to be assertoric in form, in the sense that what each expresses is the content of an assertion. It is this that makes “The cat is on the mat” an altogether different sort of logical entity from a mere string of names: “James Peter John.” So one could say that both sentences and propositions aim at truth. What one means by that, roughly speaking, is that only in the case of the kinds of sentence that express the content of a possible assertion does the question of truth arise. As Frege put it, “The only thing that raises the question of truth at all is the sense of sentences.” But to raise the question of truth and falsity is not necessarily to be susceptible of truth or falsity. Even an assertoric sentence, such as “The cat is on the mat,” cannot be said to be in its own right true or false.
Philosophy exists to trouble the peace of minds secure in their assumptions. Its shadow has always lain athwart the paths of commonsense thinking. To be fertile in paradox is part of its nature. At the same time the mind can never for long rest content with conclusions which smack of it. Paradox is not a resting-place, rather a spur to further thought. And for that reason, philosophical paradox is a serious matter, to which, when it is the product of a considerable mind, real intellectual importance can attach. It is something to be resolved, transcended if possible; it is not, by contrast, at least at its best and most serious, something to be laughed off.
In this Part, we have to deal with two such flights of paradox. The first, which will occupy us in this chapter, is Quine's celebrated argument for the indeterminacy of translation. The second is an argument of Kripke's which seems to show that our ordinary criteria for ascribing belief on the basis of sincere assent to propositions lead in certain cases to irresoluble contradiction. We shall argue that both are plausible only when their supporting arguments are advanced against the background of a certain, widely pervasive intellectual outlook, namely, the one we have been attacking throughout this book. Dispensing with Referential Realism, along the lines argued in Parts I–III, allows one, as we shall see, to deal rather swiftly with them.
In Chapter 3, we outlined a strategy of opposition to Referential Realism. In pursuit of that strategy we committed ourselves in chapter 4 to a defence of what we there called Wittgenstein's Slogan: “Logic must take care of itself.” We took the Slogan to be equivalent to the proposal that all “logical” questions, taking “logical” in a sense broad enough to include all questions of the meaning and reference of terms, must be capable of being settled antecedently to the assignment of truth or falsity to any contingent proposition. And we began our defence by attempting to show, in Chapters 5–7, that the ability to refer by means of a proper name does not depend on a speaker's knowing any contingent truth concerning the entity to which he refers, but only on his knowing-how to participate in some selection of the array of socially instituted practices, maintained with the general object of keeping track of items by means of their names, which we called the Name-Tracking Network.
We have assumed, in short, that what is required to implement Wittgenstein's Slogan, once it is removed from its original context in the phase of Wittgenstein's thought that culminated in the Tractatus, is some way of representing what is known in knowing a language as knowledge-how, not knowledge-that: knowledge of the workings of practices, not knowledge of the truth of propositions.
Russell's Principle in Russell's version is the dictum that “Every proposition which we can understand must be composed wholly of constituents with which we are acquainted.” In Gareth Evans's version, it is the more or less equivalent claim that it is possible for a person to have a thought about something only if he knows which particular individual in the world he is thinking about, with the rider that at some point the phrase “which individual” will have to be spelled out in terms of sensory acquaintance if the demands of the principle are to be met.
It is worth noticing right at the outset, therefore, that there are types of reference and referring expression to which neither version of the Principle appears to have any application whatsoever. Take for instance, the sentence “The King can move one square in any direction.”
“The King” is a referring expression. It picks out an object, the chess-King. It would be possible, for that matter, to envisage a chess nomenclature in which, rather than being indicated by means of definite descriptions, “The White King,” “The White Queen's Bishop,” “The White Queen's Knight's Pawn,” and so on, the objects so indicated would be baptised with proper names: “King George,” “Queen Mary,” “Kaiser Wilhelm,” “Bishop Wilberforce,” and so on.
The identity of the object picked out by the definite description “The White King,” or by an equivalent proper name, however, neither needs to be explained, nor could be explained, “by acquaintance.”
Does the universe contain, in addition to individuals, kinds and properties? This is the celebrated Problem of Universals. The traditional answers to it comprise Realism, which posits kinds and properties in addition to their individual exemplars and instances, and Nominalism, which allows the existence only of individuals. There is also a third answer, Conceptualism, which, recoiling both from the absurdities of an outright Nominalism and from the over-richly peopled universe of the Realist, assigns to kinds and properties the refuge of a shadowy existence as mental templates, or rules, for shuffling individuals into the sets, or as logicians say, extensions, associated with kind-names.
Realism was born with Plato. Nominalism, despite the efforts of Nelson Goodman or Hartry Field, is widely regarded as having died with Hobbes. The analytic tradition in philosophy has tended until very recently to alternate uneasily between the options of Conceptualism and some kind of platonic or quasi-platonic Realism. The Realism recommended both by Frege and by the early Russell was of this kind.
Thoughts, Frege agrees with Plato, are eternal, immutable essences which are neither created, nor sustained, nor in any way altered by any human activity; nor are they perceivable by any human sense. And so, Frege concludes, they exist neither in the external material world, nor in the subjective inner world: “a third realm must be recognized.”
“Third realms” and their contents sit ill, however, with the Positivism-derived naturalism and empiricism of so much analytic philosophy.
To say that self-sufficient thought always refers to a thought enmeshed in language is not to say that thought is alienated or that language cuts thought off from truth and certainty. We must understand that language is not an impediment to consciousness …
– Maurice Merleau-Ponty
Reference, Meaning, and Intention
The three forms of Referential Realism we have so far distinguished, albeit in a fairly brisk and sketchy way, account for a considerable part of what has taken place in analytic philosophy of language since 1900. They exhibit numerous incompatibilities, and the discussion of their relative merits has achieved considerable heights of complexity and acuity. We shall not, except occasionally and indirectly, enter into those discussions. Our object in this book is not to argue for or against any particular version of Referential Realism but to attack Referential Realism root and branch.
In opposition to the Referential Realist we shall contend that the entities “picked out by,” or “referred to,” or “designated by” all of the content-bearing expressions of a natural language are without exception linguistic constructs: things “constituted by linguistic convention,” in the sense of being things having no existence in nature prior to the constitution of language. At the same time we shall argue that such a claim yields neither of the absurd consequences it is generally supposed to yield.