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Congenital aortic valvar disease represents a heterogeneous population with suboptimal surgical repair or replacement outcomes. We assess our approach and short-term outcomes in this population using cardiac CT evaluation for personalised surgical planning and execution.
Methods:
We assessed patients who underwent aortic valvar surgery from February 2022 to August 2024. Pre-surgical evaluation included cardiac CT with quantitative assessment of the leaflet geometry and measures of leaflet coaptation. A standardised approach towards surgical execution guided by this assessment was established and followed.
Results:
Seventy-three patients underwent surgery at a median age of 26.0 years (interquartile range 19–44), 65.8% males. Forty-eight patients (65.8%) underwent some form of aortic valvar repair, with 22 of these 48 patients undergoing a valve-sparing aortic root replacement. The remaining 25 patients (34.2%) underwent some form of aortic valvar replacement. Mean post-surgical follow-up was 4.2 ± 6.1 months. Moderate or greater aortic regurgitation was present in 45 patients (61.6%) pre-operatively versus 2 patients (2.7%) post-operatively (p-value < 0.001). The peak and mean gradient improved from 33.2 ± 31.3 mmHg and 16.9 ± 10.7 mmHg pre-operatively, to 16.9 mmHg±10.7 mmHg and 9.5 ± 6.4 mmHg post-operatively (p-value < 0.001).
Conclusion:
The heterogeneity and complexity of the dysfunctional and/or dilated (neo-)aortic root encountered in those presenting for surgery necessitates a methodical, detailed three- and four-dimensional assessment. By applying such an approach, we have aimed to standardise not only the assessment, but also description and surgical execution in this challenging patient population. Excellent short-term results have been achieved, necessitating long-term follow-up to understand the potential benefits towards this personalised approach.
Heated online communication reveals global challenges in the digital age, often fuelled by collective outrage. This article investigates how Buddhist network perspectives, paralleling digital reality, can inform mental health. Avatamsaka philosophy provides practical ways to navigate web complexities, suggesting that individual actions ripple across society. Recognising our interdependence and the impermanence of social responses deepens understanding of communication’s broader impact and dynamic interconnected worldviews. These perspectives support relational balance and cognitive flexibility, essential for alleviating online distress and conflicts, including acceptance of present circumstances and fostering motivation for positive change. Valuing connectedness while respecting individuality helps cultivate resilience, enriching therapeutic practices.
This article tells the story of how high-ranking officials in New York State, during the early nineteenth century, designed and revised an institutional structure for a statewide public school system that offered, even demanded, a significant role for local residents in governing and operating their schools. This statebuilding initiative was pursued with equal vigor by members of the various political factions of the time. The educational system it produced was built by government action, rather than primarily growing out of civil-societal forces and voluntary/spontaneous efforts. Politicians in charge of the system consistently tried to encourage citizen engagement. Their goal was not just to improve the schools, but also to enhance self-government in American life more generally. The story anticipates debates in the contemporary field of theory and practice known as participatory governance, contributing to discussions about the possibilities for meaningful citizen control within large bureaucratic structures. Since participatory democracy presupposes and relies upon policy feedbacks, the article discusses feedbacks that emerged—or were hoped for but did not—and how they facilitated or obstructed participatory goals. It also contributes to scholarship on the activism of nineteenth-century government and speaks to conversations in the history of American education.
This article includes my 4 June 2023, comments on the specification of the baseline in Regulatory Impact Analyses that were submitted in response to the Office of Management and Budget’s (OMB’s) request for comments on its draft revisions to Circular A4, “Regulatory Analysis.” This article also includes supplemental remarks on the Office of Information and Regulatory Affairs’ (OIRA’s) Revisions to Circular A4 in Response to Public Comments. In my supplemental remarks, I clarify two regulatory situations that I believe OIRA is trying to address in its baseline guidance. I then make three points. First, I argue that the term “dynamic baseline” is preferred to “analytic baseline” because it better conveys the key point that the baseline is a forecast of future conditions. Second, I believe OIRA’s final baseline guidance still leaves agencies with too much discretion to make their own assumptions about such basic parameters in the construction of a dynamic baseline as population and economic growth, technological innovation, and climate change. Third, I argue that the use of multiple dynamic baselines should be standard practice because it makes the baseline assumptions more transparent and thus to some extent mitigates the risk of bias that can arise from an analyst’s strategic selection of a single baseline.
Cannabis use increases the risk of psychosis, but cannabis-based medicinal products may provide additional therapeutic opportunities. Decriminalisation of cannabis has led to wider availability in certain jurisdictions, while in the UK regulated medicinal preparations are not readily accessible. A more balanced approach could reduce harms while maximising potential therapeutic benefits.
This study aimed to investigate healthcare professionals’ experiences with using the PRO Palliative Care questionnaire (PRO-Pall) to identify palliative care symptoms and problems in non-specialized palliative care settings among patients with heart, lung, and kidney disease, and cancer. The study also investigated the PRO-Pall’s potential to ensure further initiatives and care.
Methods
A national, multicenter, observational study employing a mixed-methods approach. It includes quantitative analysis using an evaluation survey (n = 286) and qualitative analysis from workshops (n = 11). Quantitative data were analyzed descriptively, while qualitative data were analyzed thematically.
Results
Quantitative and qualitative data were organized according to 3 a priori-defined themes: Theme 1: Assessment of palliative symptoms, Theme 2: Support for dialogue, and Theme 3: Timely initiation of initiatives and care. The evaluation survey and qualitative interviews with healthcare professionals indicated that it was valuable to use PRO-Pall in a non-specialist palliative context to screen for symptoms and problems, as well as to initiate actions. PRO-Pall helped to structure the dialogue and had a positive effect on the quality of the conversation.
Significance of results
The findings highlight that it can be valuable to utilize the PRO-Pall in general palliative care settings for patients with heart, lung, or kidney diseases as well as cancer. When implementing PRO-Pall in practice, it is crucial to carefully consider the entire process, from administering the questionnaire to planning initiatives informed by patients’ PRO responses.
This article sketches an answer to the call for a normative foundation for the paradox perspective on corporate sustainability and also enriches an understanding of firm objectives that ought to be otherwise than profit by offering a rendering of Aristotelian virtue ethics—what I call the virtuous life of pleasure—that highlights how contemplative activity or theorein cultivates, and is essential to, virtue and eudaimonia. My claim is that the virtuous life of pleasure not only characterizes how to live the most meaningful and pleasant life, rendering it good and thus worth pursuing, but it is also, as a flourishing life, the normative foundation for safeguarding the intrinsic value of nonfinancial corporate aims, as the paradox perspective prescribes. It does so by establishing a principle of enough, which seeks to preserve integral, interdependent parts as ends in themselves and as constitutive of a larger ecosystem.
Solar geoengineering offers a speculative means to cool the planet by reflecting solar radiation into space. While some research suggests that awareness of solar geoengineering could reduce public support for decarbonization through a moral hazard mechanism, other studies indicate that it could serve as a “clarion call” that motivates further action. Using a pre-registered factorial design, we assess how sharing balanced information on solar geoengineering affects attitudes toward decarbonization policies and climate attitudes among 2,509 US residents. We do not find that solar geoengineering information affects support for decarbonization on average, though it may increase support among initially less supportive subgroups; moreover, this information tends to increase the perception that climate change is a daunting problem that cannot be resolved without decarbonization. Our results suggest that concerns about moral hazard should not discourage research on solar geoengineering – as long as the public encounters realistic messages about solar geoengineering’s role.
Nurse practitioners, especially in remote rural areas in low- and middle-income countries, initiate treatment for numerous conditions including therapy against infections. For a sustained and meaningful reduction in antimicrobial resistance, nurse practitioners should confidently play a greater role as stewards of antibiotic therapy. Therefore, this study investigated the self-confidence level, perceptions, and professional development needs of nurse practitioners as stewards of antibiotic therapy in remote countryside areas in KwaZulu-Natal, South Africa.
Methods:
Data collection took place at six healthcare facilities in rural areas in KwaZulu-Natal, South Africa. Questionnaires, with open-ended and 5-point Likert-scale-based items, were distributed to nurse practitioners employed, ie, participants, at the research sites.
Results:
One hundred and thirty (n = 130) participants filled and returned questionnaires; 31% (n = 41) and 69% (n = 89) were males and females, respectively. Over 64% (n = 83) of nurse practitioners were not aware of the extent of inappropriate utilization of antibiotics in South Africa, with a median of 3 (interquartile range (IQR 2–3). Over 70% (n = 91) of participants knew that inappropriate utilization of antimicrobials was harmful to patients, with a median of 4 (IQR 3–5). Only 30% (n = 39) of participants felt confident enough to play a meaningful role as stewards of antimicrobial therapy.
Conclusions:
There is a need for continuous professional development programs on antimicrobial stewardship to enhance self-confidence among nurse practitioners in rural areas.
The troublesome weed Johnsongrass [Sorghum halepense (L.) Pers.] is predicted to expand its range under climate change. In the process, it is likely to become more competitive in corn (Zea mays L.) production areas of the northeastern United States and southern Canada. A replicated greenhouse experiment was conducted to measure interspecific and intraspecific competition between an S. halepense biotype from central New York State (northern range edge) and corn under drought and well-watered conditions. Drought stress significantly reduced the biomass and height of corn and S. halepense in both rounds of the experiment (P < 0.001). Drought stress increased the root-to-shoot ratio of S. halepense (P < 0.001) and reduced the root-to-shoot ratio of corn (P < 0.001). In one run of the experiment, corn produced 19.3% more aboveground biomass (P < 0.001) and 6.6% more height (P < 0.001) when competing with an S. halepense plant (interspecific competition) than when competing with a second corn plant (intraspecific competition). Drought conditions increased the advantage of corn plants grown under interspecific relative to intraspecific competition (P = 0.012). In that round of the experiment, biomass of S. halepense was 12.9% higher under intraspecific competition than interspecific competition in the well-watered treatment and 15.5% higher under intraspecific competition than interspecific competition in the drought treatment (main effect of competition, P = 0.002). Differences between competition treatments were smaller in the other round of the experiment (P > 0.05). Our findings suggest that the New York S. halepense biotype used in this study may not be as competitive as biotypes found in this weed’s range core in more southern regions of the United States. However, anticipated effects of climate change may increase the abundance and competitiveness of this species in the northeastern United States.
Scholars have extensively studied the diffusion of criminal laws across the American states, and this paper examines an overlooked story of penal diffusion: the mid-twentieth-century spread of habitual offender laws. These laws, which escalated sentences for repeat offenders, proliferated across the states decades before the enactment of the three-strikes laws to which they bore remarkable resemblance. But whereas prior research has traced the legislative diffusion of habitual offender laws, this article alternatively explores how state courts’ interpretations of habitual offender laws diffused across jurisdictions. Using an innovative theoretical framework blending judicial diffusion research with literatures in neo-institutional theory, this article reveals how state courts borrowed legal decisions from other states to interpret, legitimize, and alter laws within their own jurisdictions. This reveals how state courts can shape the trajectory of legislative diffusion in enduring and profound ways. This study’s unique theoretical framework uses the history of habitual offender laws as a case study to explore underappreciated features and dynamics of the diffusion process that have shaped the development of American criminal law.
AI and Image illustrates the importance of critical perspectives in the study of AI and its application to image collections in the art and heritage sector. The authors' approach is that such entanglements of image and AI are neither dystopian or utopian but may amplify, reduce or condense existing societal inequalities depending on how they may be implemented in relation to human expertise and sensibility in terms of diversity and inclusion. The Element further discusses regulations around the use of AI for such cultural datasets as they touch upon legalities, regulations and ethics. In the conclusion they emphasise the importance of the professional expert factor in the entanglements of AI and images and advocate for a continuous and renegotiating professional symbiosis between human and machines. This title is also available as Open Access on Cambridge Core.
This article presents an analytical framework for studying implementation failure in minimum income programs targeted against poverty and applies it to a case study focused on the recent introduction in Spain of the first national minimum income programme, the Minimum Living Income (MLI). The framework combines two criteria (the type of agent potentially triggering failure, and the type of administrative challenge) to produce four types of implementation problems in targeted minimum income schemes: identification failure, administrative incapacity, nontake-up, and overpayments. We apply this framework in the case of MLI by conducting an exhaustive review of empirical research on its implementation problems. This evidence suggests that the special political circumstances in which the MLI was approved, some features of its design, and its insertion into a complex institutional landscape of regional minimum incomes, explain part of these problems. We conclude with some final remarks and recommendations.
Antimicrobial resistant infections are expected to increase the rate of antibiotic treatment failure in patients during a mass casualty incident. We aim to examine the potential impact of rising antimicrobial resistance (AMR) on medical preparedness and response to a nuclear detonation in the United States (U.S.) using a model to estimate the number of casualties with secondary bacterial infections overlaid with real-world data on the burden of antibiotic-resistant pathogens.
Methods
The population of injured individuals needing treatment was estimated from a simulation involving a 100-kiloton nuclear detonation in a major U.S. metropolitan area. Contemporary antibiotic resistance rates for eight key bacterial pathogens were derived from the SENTRY Microbiology Visualization Platform.
Results
Our model estimated that up to 65% of the casualties could be at risk to develop a secondary bacterial infection requiring antibiotic treatment which, when combined with the increasing burden of AMR in U.S., could result in up to one third of those patients who are injured and infected being at risk for treatment failure due to antibiotic resistance.
Conclusions
The burden of AMR on the emergency response to a mass casualty incident, as described, could be a significant hinderance to efforts to treat infections and protect lives.
Dissociative disorders frequently co-occur with post-traumatic stress disorder (PTSD), yet many individuals lack adequate treatment. Existing interventions often prioritise reducing arousal over promoting safety and self-soothing, tending to neglect the bodily experience.
Aims
This randomised clinical within-person pilot study examined the effects of the nest position, a physiotherapeutic intervention designed to enhance safety and self-soothing, on patients with dissociative disorders and healthy controls (German Clinical Trials Register No.: DRKS00030669).
Method
Eighteen patients with dissociative disorders and 18 healthy controls alternated between the nest position and a neutral supine position across two rounds of a measurement session. The order of the experimental conditions (nest position or supine only) was randomised for each participant. We assessed self-reported distress and comfort (Subjective Units of Distress and Comfort) and autonomic nervous system activity during three baseline phases and imagination of stressful and comforting situations.
Results
Both patients and healthy controls experienced lower distress and greater comfort in the nest position. Heart rate and sympathetic tone decreased, particularly in the healthy controls. There were no significant changes in parasympathetic tone in both groups. Linear mixed models revealed a significant effect of the nest position on distress, comfort and sympathetic tone.
Conclusions
The nest position is a potentially promising additional intervention for highly dissociative patients. Our findings help to better understand the importance of self-soothing and safety in these individuals and to address the research gap in physiotherapy within in-patient mental health care.
How can populist authoritarian incumbents justify remaining in power when the golden age they promised remains unrealized? We argue that audiovisual products such as videos are particularly suited to enlivening the histories that so many populists evoke in seeking to legitimize their rule. Political science’s traditional focus on speech-based legitimation, however, leaves audiovisual tools largely overlooked. The few studies that do engage these tools test for audience effects, but the content itself and the political strategies behind its curation and dissemination remain undertheorized. By adding an audiovisual lens to studies of authoritarian legitimation, we identify a regime durability strategy we term selective revivification. We specify the cognitive and affective characteristics of videos that quickly communicate information-dense, emotionally evocative messages, arguing that they engagingly distill specific historical elements to portray incumbent rule as not just legitimate but also necessary. In advancing our argument, we construct an original dataset of all existing narration-based YouTube videos shared by six regime institutions in Turkey from the establishment of YouTube in 2005 to 2022 (n = 134). We use quantitative analysis to identify when video usage emerges as a strategy, as well as patterns of dissemination and content elements. We then use intertextual analysis to extract common historical themes and production techniques. The audiovisual tools we specify and the selective revivification strategy they enable fill gaps in studies of authoritarian legitimation while adding to political scientists’ toolkits for wider inquiry.
Hallucinations and other unusual sensory experiences (USE) are common in people with psychosis. Yet access to effective psychological therapies remains limited. We evaluated if we can increase access to psychological therapy by using a brief treatment, focused only on understanding and dealing with hallucinations (Managing Unusual Sensory Experiences; MUSE), delivered by a less trained but more widely available workforce that harnessed the benefits (engaging content, standardisation) afforded by digital technology. The delivery of this in a real-world setting was considered within the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework.
Method:
Thirty-eight people with psychosis and distressing hallucinatory experiences were offered sessions of MUSE, delivered by trained and supervised assistant psychologists. MUSE was evaluated within an uncontrolled study conducted in routine clinical practice. Assessments pre- and post-treatment enabled consideration of the impact of the real-world intervention.
Results:
There was good uptake (88.4%), and receipt of MUSE (89% received four or more sessions). On average participants received 8.69 sessions. The participants reported significant reductions in voice hearing, paranoia, as well as improved quality of life. The feedback from the participants indicated that MUSE delivered by a less trained workforce was acceptable and beneficial.
Conclusions:
In a real-world setting we were able to offer and deliver sessions of a brief psychological psycho-education and coping skills enhancement package to people with distressing USE in the context of psychosis. The delivery of MUSE when considered against the NASSS framework appears to be a good candidate for adoption in services.
Individuals with childhood experience of out-of-home care (OHC) face elevated risks of criminal behavior and poor mental health compared with the majority population. Evidence on how trajectories of offending and psychiatric disorders covary among individuals with experience of OHC is needed. This study is based on a cohort of 14,608 individuals (n = 1,319 with OHC experience) born in the Stockholm metropolitan area in 1953 (49% women) from birth to age 63 (2016). Group-based multi-trajectory modeling among those with at least one offense or psychiatric disorder (40.5% of the men, 16.6% of the women) identified four co-occurring trajectories for both sexes. Multinomial regression analyses showed that adolescent OHC placement, particularly in institutions and for behavioral reasons, was linked to higher odds of early-adulthood-limited or decreasing offending and psychiatric trajectories. Most individuals recover from offending and psychiatric disorders by retirement, but placed individuals in particular remain at high risk for offending, alongside psychiatric disorders, throughout early adulthood. Early assessment and tailored attention to needs and risk levels is important when designing long-term care services to mitigate this. Research on underlying mechanisms, and on collaboration between the welfare, justice, and psychiatric care systems, can help to design effective intervention strategies and policies.
The various meanings of ‘legitimacy’ – Constitution-making procedure as a tool to achieve the right content of a new constitutional document – The effect of the procedure on the actual social and political context – Trade-offs between the various conceptions of legitimacy – Inherent tensions between transparency and political compromise, and between inclusivity and elite support – Direct democratic involvement aggravating polarisation – When the time is not ripe for constitution-making, recommended substitute strategies – Various procedural options: popular drafting, constituent assemblies, ordinary parliaments, expert bodies, roundtables, referenda – The dangers of (Kelsenian) constitutional revolutions
Over the past decade, several multi-institutional research consortia have formed within the North American pediatric surgical community. In this article, we describe our experience with the creation and implementation of the Eastern Pediatric Surgery Network, a large and comprehensive research consortium designed to produce a wide array of high-quality clinical studies within our subspecialty. In 2020, a vision statement and rules of governance were established at thirteen academic pediatric surgery divisions in the eastern United States. The research consortium was organized based on four major pillars, namely legal ownership of aggregate data, horizontal leadership structure, mandatory participation in adopted studies, and a broad research portfolio that encompasses the full breath of the specialty. Over the past five years, the number of research projects has dramatically expanded over time and includes participation from 24 different medical centers. Despite a lack of dedicated sponsored extramural support for most projects, there have been 28 abstracts presented at national conferences and 12 manuscripts published in peer-reviewed journals. It is our hope that sharing our experience with creating this organization can help to inform others interested in establishing the academic infrastructure to engage in multi-institutional, evidence-based clinical research in other medical specialties and beyond.