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Urgent care centers (UCCs) have reported high rates of antibiotic prescribing for acute respiratory tract infections. Prior UCC studies have generally been limited to single networks. Broadly generalizable stewardship efforts targeting common diagnoses are needed. This study examines the effectiveness of an antibiotic stewardship intervention in reducing inappropriate prescribing for bronchitis and viral upper respiratory tract infections (URTIs) in UCCs.
Design:
A quality improvement study comparing inappropriate antibiotic prescribing rates in UCCs after the introduction of an antibiotic stewardship intervention.
Setting:
Forty-nine UCCs in 27 different networks from 18 states, including 1 telemedicine site.
Participants:
Urgent care clinicians from a national collaborative of UCCs, all members of the Urgent Care Association.
Methods:
The intervention included signing a commitment statement and selecting from 5 different intervention options during 3 plan-do-study-act cycles. The primary outcome was the percentage of urgent care encounters for viral URTIs or bronchitis with inappropriate prescribing, stratified by clinician engagement and diagnosis. A 3-month baseline and 9-month intervention period were compared using a regression model using a generalized estimating equation.
Results:
Among 15,385 encounters, the intervention was associated with decreases in inappropriate antibiotic prescribing for bronchitis (48% relative decrease, aOR = 0.52; 95% CI, 0.33–0.83) and viral URTIs (33%, aOR = 0.67; 95% CI, 0.55–0.82) among actively engaged clinicians compared to baseline. The intervention did not result in significant changes for clinicians not actively engaged.
Conclusions:
This intervention was associated with reductions in inappropriate prescribing among actively engaged clinicians. Implementing stewardship interventions in UCCs may reduce inappropriate antibiotic prescriptions for common diagnoses; however, active clinician engagement may be necessary.
The Wolff–Parkinson–White pattern is a delta wave frequently detected in school-based cardiovascular screening programs in Japan. Although most children with Wolff–Parkinson–White pattern are asymptomatic, initial symptoms may include syncope or sudden death, necessitating accurate diagnosis and management. Delta waves can also indicate a fasciculoventricular pathway, which poses no risk and does not require management.
Methods:
We reviewed the medical records of patients referred to our hospital between April 2008 and March 2022 to evaluate the electrocardiographic signs of the Wolff–Parkinson–White pattern. The existence of Wolff–Parkinson–White syndrome and fasciculoventricular pathway were determined based on atrioventricular block and QRS waveform changes after adenosine administration during sinus rhythm.
Results:
The study cohort included 127 children (65 males; median age: 12.8 years, resting heart rate: 75 beats/min, PR interval: 109 ms, and QRS duration: 101 ms). The adenosine administration test revealed a fasciculoventricular pathway, Wolff–Parkinson–White syndrome, and indeterminate findings in 64, 54, and 9 children, respectively. More than 60% of children with a QRS duration ≤ 120 ms had a fasciculoventricular pathway. Age ≤ 12 years, QRS duration >120 ms, and type A category (children with R/S ratios >1 in lead V1) were identified as independent risk factors for Wolff–Parkinson–White syndrome. No adverse events were observed in any child.
Conclusions:
The adenosine administration test is safe and feasible for differentiating Wolff–Parkinson–White syndrome from fasciculoventricular pathways and can reduce the unnecessary management of children with fasciculoventricular pathways.
The genus Enenterum Linton, 1910 comprises species which parasitize herbivorous kyphosid fish. In the present study, a new species is described based on fresh specimens collected from Kyphosus incisor from Rio de Janeiro. The new species is characterized by having the oral sucker infundibuliform with 10 lobes, prepharynx two times longer than pharynx, presence of oesophagus, testes slightly lobed, round ovary and rectum with muscular sphincter connected to the anus. New genetic sequences include partial 18S and 28S rDNA and ITS1-5.8S-ITS2. The phylogenetic analyses place Enenterum gomesae n. sp. as sister of Enenterum aureum, corroborating the morphological analyses. Enenterum aureum (=E. pimelopteri) previously described from Kyphosus spp. from Rio de Janeiro is now considered E. gomesae n. sp. The new species represents the only South American species so far described for this genus.
Anxiety disorders and treatment-resistant major depressive disorder (TRD) are often comorbid. Studies suggest ketamine has anxiolytic and antidepressant properties.
Aims
To investigate if subcutaneous racemic ketamine, delivered twice weekly for 4 weeks, reduces anxiety in people with TRD.
Method
The Ketamine for Adult Depression Study was a multisite 4-week randomised, double-blind, active (midazolam)-controlled trial. The study initially used fixed low dose ketamine (0.5 mg/kg, cohort 1), before protocol revision to flexible, response-guided dosing (0.5–0.9 mg/kg, cohort 2). This secondary analysis assessed anxiety using the Hamilton Anxiety (HAM-A) scale (primary measure) and ‘inner tension’ item 3 of the Montgomery–Åsberg Depression Rating Scale (MADRS), at baseline, 4 weeks (end treatment) and 4 weeks after treatment end. Analyses of change in anxiety between ketamine and midazolam groups included all participants who received at least one treatment (n = 174), with a mixed effects repeated measures model used to assess the primary anxiety measure. The trial was registered at www.anzctr.org.au (ACTRN12616001096448).
Results
In cohort 1 (n = 68) the reduction in HAM-A score was not statistically significant: −1.4 (95% CI [−8.6, 3.2], P = 0.37), whereas a significant reduction was seen for cohort 2 (n = 106) of −4.0 (95% CI [−10.6, −1.9], P = 0.0058), favouring ketamine over midazolam. These effects were mediated by total MADRS and were not maintained at 4 weeks after treatment end. MADRS item 3 was also significantly reduced in cohort 2 (P = 0.026) but not cohort 1 (P = 0.96).
Conclusion
Ketamine reduces anxiety in people with TRD when administered subcutaneously in adequate doses.
We argue that libertarianism (roughly, the thesis that we have indeterministic, libertarian free will) is compatible with God’s infallible foreknowledge. We use eternalism (roughly, the thesis that reality is a 4-dimensional block and that past, present, and future objects exist) as an explanatory stepping stone between libertarianism and God’s foreknowledge: eternalism entails that (and comes close to explaining how) an omniscient God would know what we decide in the future even if we have libertarian free will. This account also explains what is wrong with standard fatalist arguments for the incompatibility of free will and God’s foreknowledge.
Dark patterns have become a pervasive issue around the world. However, Indonesia has not taken any action to deal with the situation. This article aims to analyse the issue of dark patterns in digital platforms from Indonesia’s consumer protection law perspective. It contends that Indonesia’s consumer protection law is not adequate in overcoming the issue of dark patterns in digital platforms. Several laws regulate basic principles and provisions that indirectly prohibit dark patterns, but these regulations can only be applied to certain forms of dark patterns and are difficult to implement. The article suggests that Indonesia must specifically regulate the prohibition of the practices of dark patterns in its current law. The regulations do not have to define the term “dark patterns” directly; however, they should expressly regulate prohibitions against the practice of using design interfaces in a way that subverts or impairs consumers’ autonomy and/or exploits consumers’ behavioural biases.
This study is designed to understand embarrassment in the second/foreign language (L2) context. Following a mixed-method design, in Phase 1, a sample of 141 tertiary-level Austrian English language learners were asked to write a narrative about their experiences of embarrassment in their language learning histories. Analyzing the narratives showed that L2 embarrassment is a multidimensional construct that is frequently experienced by a range of language learners. In Phase 2, we developed and validated an L2 classroom speaking embarrassment (L2CSE) scale among a sample of 402 international English language learners drawing on the literature and analysis of the narratives. Data showed that L2 embarrassment is best represented by a bifactor exploratory structural equation model, capturing both general and specific aspects of L2 embarrassment. We found that a supportive classroom environment and fostering a growth mindset can decrease the risk of L2 embarrassment. As expected, L2 embarrassment was a negative predictor of willingness to communicate and self-perceived language proficiency. These initial findings suggest that L2 embarrassment could be an important and influential emotion in the language learning classroom context which requires further research.
Model selection (MS) and model averaging (MA) are two popular approaches when many candidate models exist. Theoretically, the estimation risk of an oracle MA is not larger than that of an oracle MS because the former is more flexible, but a foundational issue is this: Does MA offer a substantial improvement over MS? Recently, seminal work by Peng and Yang (2022) has answered this question under nested models with linear orthonormal series expansion. In the current paper, we further respond to this question under linear nested regression models. A more general nested framework, heteroscedastic and autocorrelated random errors, and sparse coefficients are allowed in the current paper, giving a scenario that is more common in practice. A remarkable implication is that MS can be significantly improved by MA under certain conditions. In addition, we further compare MA techniques with different weight sets. Simulation studies illustrate the theoretical findings in a variety of settings.
Numerous transport stirrup jars have been found at the site of Pefkakia. Most were manufactured in Crete with some from the Greek mainland. There were also at least two Canaanite jars from the Carmel coast. These finds and the first results of petrographic analysis attest to the site's role as a major Aegean harbour.
The American state was a republic of patrons and clients throughout the Long Nineteenth Century. Unequal ties of hierarchy and reciprocity went far beyond the partisan administration and electioneering that we associate with the spoils system. As a form of “belated feudalism,” clientelism proved resilient because it was a familial property relation embedded within a diverse and changing society. Officeholding politics subsumed a host of racialized and gendered dependents—White men of lower status, women, children, and the enslaved—into the penumbra of the state, which itself was governed via the extended party household. What elements of patron–client relations endured or changed from the colonial inheritance until the New Deal? This article reinterprets the republic’s classical age, first, by exploring the origins of party patrimonialism, and then, by examining the dynamics of officeholding political economy and the rise of markets for patronage. Political rule before the New Deal had a different orientation. Clientelism fused older lineages of dependence with the kind of profit-seeking exchanges typical of the burgeoning capitalist economy. It was this mixed state, at once patrimonial and capitalist, that proved so difficult to reform at the turn of the twentieth century.
Natural disasters occur unexpectedly, leading to long-term consequences like obesity. That contributes to various noncommunicable diseases such as cardiovascular disease, diabetes, and cancer. This review aimed to examine the link between natural disasters and obesity, along with related risk factors.
Objective
This systematic review aimed to examine the relationship between natural disasters and obesity, as well as the associated risk factors.
Methods
A thorough search was conducted using electronic databases such as PubMed, Scopus, Web of Science, HINARI, and Google Scholar. Additional articles were manually searched. Studies that reported weight gain and risk factors were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) tools. Data were collected from eligible articles and synthesized.
Results
The participants in this research ranged from 3 months to 67 years old. Of the 17 articles, 11 focused on children, while the 5 focused on adults and 1 on adolescents. All studies followed a cohort design, with follow-up periods varying from 6 months to 15.5 years. Results indicated weight gain post-disaster, with risk factors including sedentary behavior, unhealthy eating habits, maternal high Body Mass Index (BMI), mixed feeding, stress, alcohol consumption, coastal residence, temporary housing, and timing from disaster onset.
Conclusions
This research emphasizes the significance of addressing post-disaster obesity as a pivotal aspect of public health, suggesting its integration with immediate priorities such as trauma management. Emphasizing its long-lasting effects across generations, the study offers policymakers valuable insights to develop effective approaches in tackling post-disaster obesity.
Azooxanthellate corals of Rhizangiidae, with their distinctive morphological and ecological features, are widely distributed across global oceans but remain under-studied due to identification challenges. Comprehensive underwater surveys across diverse marine habitats such as rocky reefs and submerged shipwrecks were undertaken, and findings highlighted the exclusive presence of Culicia stellata in natural rocks, off the coast of Kaup for the first time in Indian EEZ. The study also records the presence of Cladangia exusta, nearly six decades after the first record from off Cochin, Laccadive Sea. This research presents a detailed study of the taxonomic description, distribution, and ecological preferences of Cladangia exusta and Culicia stellata in the Laccadive Sea. This study underscores the importance of accurate species identification for effective conservation strategies and enriching biodiversity records.
Mass public opinion on globalization shows a persistent gender gap, but explanations for this gap differ. In the context of Africa, understanding this gender gap is particularly important because of women’s growing representation in legislatures and the rapid expansion of global economic flows on the continent. Why are women on average more skeptical of foreign economic actors? We consider this question across Sub-Saharan African countries, using Chinese economic engagement as a salient, visible form of economic globalization. Numerous studies have explored the impact of China’s presence on Africans’ attitudes toward China, but we know little about a documented gender gap in these attitudes. We explore the roots of this gap from an angle of economic vulnerability, positing that women at higher risk of a negative economic impact of Chinese engagement are more likely to view China negatively than their male counterparts. Using multilevel analyses of up to 84,000 respondents from up to 37 countries, we find a consistent pattern of economic vulnerability explaining the gender gap in attitudes, and factors associated with economic security mitigating it. Our findings suggest that economic vulnerability shapes attitudes differently across genders, and that increasing representation of women in African legislatures may have implications for policies toward Chinese engagement.