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To characterize postextraction antibiotic prescribing patterns, predictors for antibiotic prescribing and the incidence of and risk factors for postextraction oral infection.
Retrospective analysis of a random sample of veterans who received tooth extractions from January 1, 2017 through December 31, 2017.
VA dental clinics.
Overall, 69,610 patients met inclusion criteria, of whom 404 were randomly selected for inclusion. Adjunctive antibiotics were prescribed to 154 patients (38.1%).
Patients who received or did not receive an antibiotic were compared for the occurrence of postextraction infection as documented in the electronic health record. Multivariable logistic regression was performed to identify factors associated with antibiotic receipt.
There was no difference in the frequency of postextraction oral infection identified among patients who did and did not receive antibiotics (4.5% vs 3.2%; P = .59). Risk factors for postextraction infection could not be identified due to the low frequency of this outcome. Patients who received antibiotics were more likely to have a greater number of teeth extracted (aOR, 1.10; 95% CI, 1.03–1.18), documentation of acute infection at time of extraction (aOR, 3.02; 95% CI, 1.57–5.82), molar extraction (aOR, 1.78; 95% CI, 1.10–2.86) and extraction performed by an oral maxillofacial surgeon (aOR, 2.29; 95% CI, 1.44–3.58) or specialty dentist (aOR, 5.77; 95% CI, 2.05–16.19).
Infectious complications occurred at a low incidence among veterans undergoing tooth extraction who did and did not receive postextraction antibiotics. These results suggest that antibiotics have a limited role in preventing postprocedural infection; however, future studies are necessary to more clearly define the role of antibiotics for this indication.
ABSTRACT IMPACT: This study is designed to address a critical gap in our understanding of how aging patients and caregivers recognize and respond to clinically important changes in heart failure symptoms during vulnerable transitions. OBJECTIVES/GOALS: Research on family involvement in heart failure (HF) symptom response is limited. Our objective is to examine HF symptom monitoring processes in couples after HF hospitalization, and quantify how coupled symptom assessments predict symptom response, patient clinical events, care strain, and dyad health during the high-risk post-discharge period. METHODS/STUDY POPULATION: This is an ongoing T2 translational study that employs an intensive longitudinal design. Adults aged ≥65 years hospitalized for HF and their caregiving spouse/partner are enrolled. The target n is 48 dyads. Over 5 weeks of follow-up, dyads complete daily diaries assessing patient HF symptoms. Clinical biomarkers of HF severity (NTproBNP, ST2) are also collected. Primary study endpoints are dyads’ HF symptom response behaviors and caregiver strain; secondary endpoints are dyads’ health status and patient clinical events. Dyadic dynamics of symptom assessment will first be characterized using dyadic autoregressive time series models. Subsequently, we will extract cross-partner effect parameters from the time series models and test whether dyadic effects predict the trajectories of each of our endpoints. RESULTS/ANTICIPATED RESULTS: This study is currently underway. In line with our study hypotheses, we anticipate that couples who assess patient symptoms similarly (dyadic agreement), and whose symptom assessments accurately reflect clinical severity, will be more likely to respond to symptoms appropriately with lower stress to the caregiving partner, and have better trajectories of health (self-reported and clinical). Characterizing dyadic symptom dynamics will provide important insight into the day-to-day process of symptom recognition in couples. Further, quantifying dyadic symptom dynamics in relation to our endpoints will provide information on the clinical value of dyadic symptom agreement, and whether it might be a target for future interventions to support better symptom response and health outcomes for both dyad members. DISCUSSION/SIGNIFICANCE OF FINDINGS: This project innovates on existing paradigms by applying family-level theory and techniques to better understand and support interventions for couples during post-discharge HF transitions - a vulnerable period for older adults that has traditionally been studied almost exclusively at the patient-level, with marginal success.
Influenza vaccine effectiveness (VE) wanes over the course of a temperate climate winter season but little data are available from tropical countries with year-round influenza virus activity. In Singapore, a retrospective cohort study of adults vaccinated from 2013 to 2017 was conducted. Influenza vaccine failure was defined as hospital admission with polymerase chain reaction-confirmed influenza infection 2–49 weeks after vaccination. Relative VE was calculated by splitting the follow-up period into 8-week episodes (Lexis expansion) and the odds of influenza infection in the first 8-week period after vaccination (weeks 2–9) compared with subsequent 8-week periods using multivariable logistic regression adjusting for patient factors and influenza virus activity. Records of 19 298 influenza vaccinations were analysed with 617 (3.2%) influenza infections. Relative VE was stable for the first 26 weeks post-vaccination, but then declined for all three influenza types/subtypes to 69% at weeks 42–49 (95% confidence interval (CI) 52–92%, P = 0.011). VE declined fastest in older adults, in individuals with chronic pulmonary disease and in those who had been previously vaccinated within the last 2 years. Vaccine failure was significantly associated with a change in recommended vaccine strains between vaccination and observation period (adjusted odds ratio 1.26, 95% CI 1.06–1.50, P = 0.010).
Weed control of paraquat can be erratic and may be attributable to differing species sensitivity and/or environmental factors for which minor guidance is available on commercial labels. Therefore, the objectives of this research were to quantify selectivity of paraquat across select weed species and the influence of environmental factors. Experiments were performed under controlled conditions in the greenhouse and growth chamber. Compared with purple deadnettle (dose necessary to reduce shoot biomass by 50% = 39 g ai ha−1), waterhemp, Palmer amaranth, giant ragweed, and horseweed were 4.9, 3.3, 1.9, and 1.3 times more sensitive to paraquat, respectively. The injury progression rate over 3 d after treatment (DAT) was a more accurate predictor of final efficacy at 14 DAT than the lag phase until symptoms first appeared. For example, at the 17.5 g ha−1 dose, the injury rate of waterhemp and Palmer amaranth was, on average, 3.6 times greater than that of horseweed and purple deadnettle. The influence of various environmental factors on paraquat efficacy was weed specific. Applications made at sunrise improved control of purple deadnettle over applications at solar noon or sunset. Lower light intensities (200 or 600 μmol m−2 s−1) surrounding the time of application improved control of waterhemp and horseweed more than 1,000 μmol m−2 s−1. Day/night temperatures of 27/16 C improved horseweed and purple deadnettle control compared with day/night temperatures of 18/13 C. Though control was positively associated with injury rates in the application time of day and temperature experiments, a negative relationship was observed for waterhemp in the light-intensity experiment. Thus, although there are conditions that enhance paraquat efficacy, the specific target species must also be considered. These results advocate paraquat dose recommendations, currently based on weed height, be expanded to address sensitivity differences among weeds. Moreover, these findings contrast with paraquat labels stating temperatures of 13 C or lower do not reduce paraquat efficacy.
Hydrogen lithography has been used to template phosphine-based surface chemistry to fabricate atomic-scale devices, a process we abbreviate as atomic precision advanced manufacturing (APAM). Here, we use mid-infrared variable angle spectroscopic ellipsometry (IR-VASE) to characterize single-nanometer thickness phosphorus dopant layers (δ-layers) in silicon made using APAM compatible processes. A large Drude response is directly attributable to the δ-layer and can be used for nondestructive monitoring of the condition of the APAM layer when integrating additional processing steps. The carrier density and mobility extracted from our room temperature IR-VASE measurements are consistent with cryogenic magneto-transport measurements, showing that APAM δ-layers function at room temperature. Finally, the permittivity extracted from these measurements shows that the doping in the APAM δ-layers is so large that their low-frequency in-plane response is reminiscent of a silicide. However, there is no indication of a plasma resonance, likely due to reduced dimensionality and/or low scattering lifetime.
A significant proportion of inpatient antimicrobial prescriptions are inappropriate. Post-prescription review with feedback has been shown to be an effective means of reducing inappropriate antimicrobial use. However, implementation is resource intensive. Our aim was to evaluate the performance of traditional statistical models and machine-learning models designed to predict which patients receiving broad-spectrum antibiotics require a stewardship intervention.
We performed a single-center retrospective cohort study of inpatients who received an antimicrobial tracked by the antimicrobial stewardship program. Data were extracted from the electronic medical record and were used to develop logistic regression and boosted-tree models to predict whether antibiotic therapy required stewardship intervention on any given day as compared to the criterion standard of note left by the antimicrobial stewardship team in the patient’s chart. We measured the performance of these models using area under the receiver operating characteristic curves (AUROC), and we evaluated it using a hold-out validation cohort.
Both the logistic regression and boosted-tree models demonstrated fair discriminatory power with AUROCs of 0.73 (95% confidence interval [CI], 0.69–0.77) and 0.75 (95% CI, 0.72–0.79), respectively (P = .07). Both models demonstrated good calibration. The number of patients that would need to be reviewed to identify 1 patient who required stewardship intervention was high for both models (41.7–45.5 for models tuned to a sensitivity of 85%).
Complex models can be developed to predict which patients require a stewardship intervention. However, further work is required to develop models with adequate discriminatory power to be applicable to real-world antimicrobial stewardship practice.
The aim of this study was to investigate whether lower lithium levels (LoLi) or olanzapine doses (LoOL) are risk factors for future mood episodes in patients with bipolar I disorder.
A post-hoc analysis of the olanzapine-lithium-maintenance study  was performed using proportional hazards Cox regression models and marginal structural models (MSMs), adjusting for non-random assignments of dose during treatment.
The LoLi group (< 0.6 mmol/L) had a significantly increased risk of manic/mixed (hazard ratio [HR] = 1.96, p = 0.042), but not depressive (HR = 2.11, p = 0.272) episodes, compared to the combined medium (0.6–0.79 mmol/L) and high lithium level (≥ 0.8 mmol/L) groups. There was no significant difference in risk between the two higher lithium level groups (0.6-0.79 mmol/L; ≥ 0.8 mmol/L) for new manic/mixed (HR = 0.96, p = 0.893) or depressive (HR = 0.95, p = 0.922) episodes. The LoOL group (< 10 mg/day) showed a significantly increased risk of depressive (HR = 2.24, p = 0.025) episodes compared to the higher olanzapine (HiOL) dose group (HiOL: 10–20 mg/day), while there was no statistically significant difference in risk for manic/mixed episodes between the two groups (HR = 0.94, p = 0.895).
Lithium levels ≥ 0.6 mmol/L and olanzapine doses ≥ 10 mg/day may be necessary for optimal protection against manic/mixed or depressive episodes, respectively in patients with bipolar I disorder.
Neuroprotective effects of lithium have been well documented in tissue cultures and animal models. The evidence for lithium related neuroprotection in human subjects is limited and inconsistent, likely due to methodological heterogeneity.
To investigate the effects of lithium on brain chemistry and structure, we recruited bipolar patients selected for substantial illness burden and varied the exposure to lithium by using strict inclusion criteria.
We obtained 1.5T magnetic resonance imaging data from 27 bipolar patients with at least 2 years of ongoing lithium treatment (Li group), 16 subjects with < 3 months lifetime exposure to lithium >2 years ago (non-Li group) and 21 healthy controls. Patient groups had to have at least 10 years of illness and 5 episodes.
The non-Li group had significantly lower hippocampal volumes (t = 4.68,corrected p < 0.05) and prefrontal cortex N-acetyl aspartate (NAA) levels (t = −2.91,corrected p < 0.05) than controls, who showed comparable hippocampal volumes and NAA levels to the Li treated subjects. Duration of illness was negatively associated with NAA levels only in the non-Li, but not the Li group.
Among patients selected for substantial illness burden, only those with no or minimal lifetime Li exposure had significantly lower prefrontal NAA levels and hippocampal volumes than controls. Patients with at least 2 years of ongoing Li treatment showed no such changes, despite substantial burden of illness. These findings provide indirect support for neuroprotective effects of lithium and negative effects of illness burden on brain chemistry and structure in patients with bipolar disorders.
Prior studies indicate greater disease burden for obesity among rural compared with urban residents but no differences for mood disorder based on geographic location. Recent attention has focused on the need to examine regional rural–urban disparities in disease burden. We focused on mood disorders and obesity prevalence within three southeastern Minnesota counties served by the Mayo Clinic Center for Translational Science Award, in Rochester, Minnesota, as these were top priorities identified in community health needs assessments.
Cross-sectional study to assess the association of rural–urban locality on 5-year (2009–2014) prevalence of mood disorder and obesity obtained using the Rochester Epidemiological Project medical records linkage system, among subjects residing in three mixed rural–urban counties on April 1, 2014. Multivariable analyses adjusted for demographics, socioeconomic status using an individual housing-based measure, and counties.
The study cohort (percent rural location) included 91,202 (15%) for Olmsted, 10,197 (51%) in Dodge, and 10,184 (57%) in Wabasha counties. On multivariate analysis, 5-year prevalence of mood disorders and obesity was significantly greater for urban compared with rural residents, after adjusting for confounders; odds ratios (95% confidence intervals): 1.21 (1.17–1.26), P < 0.001, and 1.05 (1.01–1.10), P = 0.016, respectively. Observed effects were not modified in additional models adjusted for health care utilization (HCU; ≥1 general medical examination visit and flu vaccination).
Rural–urban health disparities for burden of mood disorders and obesity are independent of socioeconomic status and HCU in a Midwestern community. It is important to assess potential regional heterogeneity of rural–urban disparities on health outcomes.
Clozapine is the most effective antipsychotic medication, but it has the highest propensity for metabolic side effects. A clozapine clinic was established within an early intervention for psychosis service to facilitate the timely commencement of clozapine and to manage the associated adverse effects. This study describes the changes in the weight, body mass index (BMI), waist circumference and blood pressure after 6 months in young people commenced on clozapine.
This was a prospective cohort study of all young people, aged 15–24 years, commenced on clozapine within an early intervention service in Melbourne, Australia, between 01.04.2016 and 30.06.2018. Continuous data were analyzed with paired t-test and categorical with Wilcoxon signed-rank test.
Twenty-six young people received 6 months of treatment with clozapine, of whom the mean age was 19.8 years (s.d. ±3.1) and 66.7% were male. After 6 months, the mean weight gain was 5.1 kg (s.d. ±10.1 kg) and over half (53.8%) gained clinically significant weight. The proportion of young people classified as either overweight or obese rose from 69.2% to 88.5% (p = 0.006). The proportion of young people with a waist circumference above the recommended parameters increased from 57.9% to 78.9% (p = 0.008). Hypertension was present in 30%, and after 6 months, 45% had hypertension (p = 0.64). Metformin was prescribed to 34.6%, typically to those with the greatest and most rapid weight gain.
Among young people with treatment resistant psychosis, clozapine is associated with significant metabolic side effects in the early stages of commencement. More interventions aimed at attenuating this weight gain are needed.
To estimate the effects of continuous daily treatment with different acid suppressants on the risk of ventilator-associated events in critically ill patients.
Retrospective cohort study.
Adult critically ill patients who underwent mechanical ventilation for ≥3 days during an inpatient admission between January 2006 and December 2014.
We estimated the 30-day cumulative risk ratios (RRs) for ventilator-associated events comparing daily proton pump inhibitor (PPI) versus daily histamine-2-receptor antagonist (H2RA) strategies while controlling for time-fixed and time-varying confounding and accounting for competing events.
Of 6,133 patients, on ventilation day 3, 58.8% received H2RAs, 26.1% received PPIs, and 4.1% received sucralfate. Patients frequently changed treatment throughout follow-up. Among 4,595 patients receiving PPIs or H2RAs on day 3, we found no differences in risk estimates for ventilator mortality and extubation alive comparing daily PPI versus daily H2RA strategies: RR, mortality, 1.03 (95% CI, 0.89–1.22); extubation alive, 1.00 (95% CI, 0.96–1.03). We found similar results after accounting for PPI dose. For possible ventilator-associated pneumonia (PVAP) and infection-related ventilator-associated complication (IVAC), point estimates were larger, but the 95% CIs crossed 1.0: RR PVAP, 1.25 (95% CI, 0.80–1.94); IVAC, 0.89 (95% CI, 0.64–1.17). The magnitude of effect estimates depended on PPI dose. The RR for PVAP, high-dose PPI versus H2RA, was 1.53 (95% CI, 0.82–2.51), and for low-dose PPI versus H2RA, the RR was 0.97 (95% CI, 0.47–1.63). For IVAC, high-dose PPI versus H2RA, the RR was 1.01 (95% CI, 0.66–1.42), and for low-dose PPI versus H2RA, the RR was 0.78 (95% CI, 0.50–1.11).
We estimated no effect of daily PPI versus daily H2RA on risk of mortality or extubation alive in critically ill patients. Further investigation with larger samples is warranted for PVAP and IVAC.
Management of volunteer glyphosate-resistant (GR) corn may be problematic in soybean resistant to glyphosate and 2,4-D or dicamba, as auxinic herbicides often antagonize graminicide efficacy. Field and greenhouse trials were conducted using mixtures of 2,4-D or dicamba in combination with glyphosate and clethodim-A (formulated without an adjuvant) or clethodim-SM (adjuvant-inclusive formulation) to determine the effect on volunteer GR corn control. Neither auxinic herbicide reduced clethodim efficacy, regardless of clethodim rate or formulation in field trials. However, the addition of glyphosate to these mixtures at the 35 g ai ha−1 clethodim dose reduced control from clethodim-A and clethodim-SM by 62% to 75% and 27% to 47%, respectively. Increasing the clethodim dose to 105 g ha−1 or greater in combination with glyphosate and either auxinic herbicide generally restored clethodim efficacy (74% to 98% control); in one site-year, the addition of glyphosate plus dicamba to clethodim-A at 140 g ha−1 still reduced control by 34%. In greenhouse experiments, clethodim-A efficacy was reduced by 17% and 28% when applied with glyphosate plus 420 and 1,680 g ae ha−1 2,4-D, respectively, in the absence of crop oil concentrate (COC). Increasing the dose of dicamba in a similar mixture had a negligible effect. Irrespective of auxinic herbicide dose, the inclusion of COC to clethodim-A mixtures with glyphosate plus 2,4-D or dicamba resulted in ≥ 90% control. These results specify an enhanced risk of reduced clethodim efficacy on volunteer GR corn when glyphosate is added to mixtures containing 2,4-D or dicamba. To optimize control from these mixtures, clethodim should be applied at ≥ 105 g ha−1 and should include an activator adjuvant in the form of COC and/or an adjuvant-inclusive clethodim formulation. This recommendation contrasts with several labels of clethodim that do not require COC when applied with adjuvant-loaded glyphosate products.
Constitutional scholars emphasize the importance of an enduring, stable constitutional order, which North and Weingast (1989) argue is consistent with credible commitments to sustainable fiscal policies. However, this view is controversial and has received little empirical study. We use 19th-century US state-level data to estimate relationships between constitutional design and the likelihood of a government default. Results indicate that more entrenched and less specific constitutions are associated with a lower likelihood of default.
Anxiety disorders are among the most prevalent psychiatric conditions. Despite many proven pharmacological and non-pharmacological treatments available, high rates of partial response and low rates of long-term remission remain. Ketamine has been receiving increasing attention as an interventional treatment modality in psychiatry, especially among refractory conditions, including major depressive disorder. There is limited yet growing evidence to support the use of ketamine in anxiety disorders. In this review of the literature, we present case reports, case series, and controlled trials demonstrating proof-of-concept for its potential role in the treatment of anxiety and anxiety spectrum disorders. Its unique mechanism of action, rapid onset, and high rate of response have driven its use in clinical practice. Ketamine is generally well tolerated by patients and has a limited side effect profile; however, the effects of long-term use are unknown. While there is a growing body of research and increasing clinical experience to suggest ketamine may have clinical applications in the treatment of refractory anxiety disorders, further research to determine long-term safety and tolerability is indicated.
The pore structure of vapour deposited ASW is poorly understood, despite its importance to fundamental processes such as grain chemistry, cooling of star forming regions, and planet formation. We studied structural changes of vapour deposited D2O on intra-molecular to 30 nm length scales at temperatures ranging from 18 to 180 K and observed enhanced mobility from 100 to 150 K. An Arrhenius type model describes the loss of surface area and porosity with a common set of kinetic parameters. The low activation energy (428 K) is commensurate with van der Waals forces between nm-scale substructures in the ice. Our findings imply that water porosity will always change with time, even at low temperatures.
During the past two decades, it has been amply documented that neuropsychiatric disorders (NPDs) disproportionately account for burden of illness attributable to chronic non-communicable medical disorders globally. It is also likely that human capital costs attributable to NPDs will disproportionately increase as a consequence of population aging and beneficial risk factor modification of other common and chronic medical disorders (e.g., cardiovascular disease). Notwithstanding the availability of multiple modalities of antidepressant treatment, relatively few studies in psychiatry have primarily sought to determine whether improving cognitive function in MDD improves patient reported outcomes (PROs) and/or is cost effective. The mediational relevance of cognition in MDD potentially extrapolates to all NPDs, indicating that screening for, measuring, preventing, and treating cognitive deficits in psychiatry is not only a primary therapeutic target, but also should be conceptualized as a transdiagnostic domain to be considered regardless of patient age and/or differential diagnosis.
Timely results from whole-plant, herbicide-resistant weed screenings are crucial to heighten grower awareness. However, the high degree of physiological dormancy of giant ragweed (Ambrosia trifida L.) seed exacerbates this process. The most effective methods for alleviating dormancy, to date, are either labor-intensive (embryo excision) or require several weeks (soil stratification). This research describes a conditioning process involving clipping and aeration of seed in water that is highly effective at alleviating dormancy and requires less skill and time compared with previous techniques. Ambrosia trifida seeds were collected over 2 yr at two different collection timings (September 25, “early”; October 25, “late”), subjected to various treatments intended to release dormancy, and evaluated for emergence over 18 d in the greenhouse. The use of germination-promoting chemicals (ethephon, gibberellic acid, and thiourea) generally provided no increase in emergence compared with water and occasionally produced seedlings with abnormal growth unsuitable for further experimentation. Conditioning yielded between 30% and 33% emergence for both early and late collections of seeds with no afterripening period compared with 0% emergence for seeds imbibed in water. Following an 8-wk period of dry storage at 4 C, conditioning yielded nearly 80% emergence for both collection timings, while emergence of seeds imbibed in water was 10% and 27% for early and late collections, respectively. Soil stratification in moist soil for 8 wk at 4 C was the second most effective treatment, yielding 46% to 49% emergence across both collections. Parameters of the Weibull function further indicated the conditioning treatment had the fastest rate of emergence and shortest lag phase between planting and first emergence. Methods to germinate A. trifida without an afterripening period have previously been unsuccessful. Therefore, the seed-conditioning method outlined in this work will be useful in expediting the confirmation of herbicide-resistant A. trifida incidences.
Few studies have examined the concurrent effects of physical disease and systemic inflammation on suicide risk in patients with depression. The authors investigated the independent contributions of chronic physical disease and systemic inflammation as indexed by C-reactive protein (CRP), on risk of suicide attempt.
In this case–control study, 1468 cases of suicide attempters and 14 373 controls, both aged 18–65 years with a diagnosis of depression during 2011–2015, were identified from the hospital-wide database. Regression models were implemented to identify separate effects of physical diseases and systemic inflammation indexed by CRP, on risk of suicide attempt.
Compared with having no physical disease, having one, two, and three or more physical diseases was associated with a 3.6-, 6.4-, and 14.9-fold increase in odds of making a suicide attempt, respectively, after adjusting for age, sex, and race/ethnicity. In a sub-sample of cases and controls with available CRP values, patients with high CRP (>3 mg/L) had 1.9 times the odds of suicide attempt compared with patients with low CRP (<1 mg/L). This association was no longer significant when controlling for the effect of physical disease.
The presence of physical disease is an important risk factor for suicide attempt among patients with depression. Systemic inflammation is likewise associated with increased risk for suicide attempt, however, this association appears to be accounted for by the presence of physical disease among patients receiving care in a medical center setting. Healthcare providers should consider the risk of suicide attempt in depressed patients burdened with multiple comorbidities.
Lithium-ion batteries featuring electrodes of silicon nanoparticles, conductive carbon, and polymer binders were constructed with electrolyte containing 1.2 M LiPF6 in ethylene carbonate and diethyl carbonate (1:1, w/w). Material binders used include polyvinylidene difluoride (PVdF), polyacrylic acid (PAA), sodium carboxymethyl cellulose (CMC), and a mixture of equal masses of CMC and PAA (CMCPAA). Hard X-ray photoelectron spectroscopy (HAXPES) was performed on the electrodes when fresh, cycled at reduced potential, and cycled one full time to study how substrate material binders affect the early formation of the solid electrolyte interphase (SEI) layer. Electrodes cycled 5, 10, and 20 times were also analyzed to discern what changes to the SEI occur after initial formation. We also present estimates of the SEI thickness by cycle count, indicating that PAA develops the thinnest SEI, followed by CMCPAA, CMC, and PVdF in order of increasing layer thickness.