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Patients with posttraumatic stress disorder (PTSD) exhibit smaller regional brain volumes in commonly reported regions including the amygdala and hippocampus, regions associated with fear and memory processing. In the current study, we have conducted a voxel-based morphometry (VBM) meta-analysis using whole-brain statistical maps with neuroimaging data from the ENIGMA-PGC PTSD working group.
Methods
T1-weighted structural neuroimaging scans from 36 cohorts (PTSD n = 1309; controls n = 2198) were processed using a standardized VBM pipeline (ENIGMA-VBM tool). We meta-analyzed the resulting statistical maps for voxel-wise differences in gray matter (GM) and white matter (WM) volumes between PTSD patients and controls, performed subgroup analyses considering the trauma exposure of the controls, and examined associations between regional brain volumes and clinical variables including PTSD (CAPS-4/5, PCL-5) and depression severity (BDI-II, PHQ-9).
Results
PTSD patients exhibited smaller GM volumes across the frontal and temporal lobes, and cerebellum, with the most significant effect in the left cerebellum (Hedges’ g = 0.22, pcorrected = .001), and smaller cerebellar WM volume (peak Hedges’ g = 0.14, pcorrected = .008). We observed similar regional differences when comparing patients to trauma-exposed controls, suggesting these structural abnormalities may be specific to PTSD. Regression analyses revealed PTSD severity was negatively associated with GM volumes within the cerebellum (pcorrected = .003), while depression severity was negatively associated with GM volumes within the cerebellum and superior frontal gyrus in patients (pcorrected = .001).
Conclusions
PTSD patients exhibited widespread, regional differences in brain volumes where greater regional deficits appeared to reflect more severe symptoms. Our findings add to the growing literature implicating the cerebellum in PTSD psychopathology.
The macro-social and environmental conditions in which people live, such as the level of a country’s development or inequality, are associated with brain-related disorders. However, the relationship between these systemic environmental factors and the brain remains unclear. We aimed to determine the association between the level of development and inequality of a country and the brain structure of healthy adults.
Methods
We conducted a cross-sectional study pooling brain imaging (T1-based) data from 145 magnetic resonance imaging (MRI) studies in 7,962 healthy adults (4,110 women) in 29 different countries. We used a meta-regression approach to relate the brain structure to the country’s level of development and inequality.
Results
Higher human development was consistently associated with larger hippocampi and more expanded global cortical surface area, particularly in frontal areas. Increased inequality was most consistently associated with smaller hippocampal volume and thinner cortical thickness across the brain.
Conclusions
Our results suggest that the macro-economic conditions of a country are reflected in its inhabitants’ brains and may explain the different incidence of brain disorders across the world. The observed variability of brain structure in health across countries should be considered when developing tools in the field of personalized or precision medicine that are intended to be used across the world.
Identify essential components of a curriculum on antimicrobial stewardship (AS) for pediatric residents.
Design:
Survey.
Setting:
Academic tertiary care children’s hospital.
Participants:
Pediatric residents and infectious diseases (ID)/AS content experts (CE), including pediatric ID faculty, fellows, nurse practitioners, and pharmacists.
Methods:
Residents were surveyed to assess prior AS experiences and usefulness of education in different AS domains (e.g., antimicrobial resistance [AMR]). CE was surveyed to identify content to include in an AS curriculum. A specific topic (e.g., resistance in Staphylococcus aureus) achieved consensus if ≥80% of CE identified the topic as “very” or “extremely” important.
Results:
Thirty-three of 110 pediatric residents responded to the resident survey (response rate 30%). Spectrum of activity (97%), empiric therapy (94%), and duration of therapy (94%) were the domains identified by the most residents as “very” or “extremely” useful. All CE responded to the CE survey (n=26). Thirty-nine of 105 topics (37%) met the consensus threshold. The domains with most topics achieving consensus were empiric therapy (11/13 topics, 85%) and duration of therapy (5/8 topics, 63%). Only one topic was identified within the domains of antibiotic allergies, diagnostics, and AMR, reflecting 18%, 14%, and 6% of the potential topics within each domain, respectively.
Conclusions:
A pediatric AS curriculum focused on empiric therapy and duration of therapy is likely to meet the needs of both learners and CEs.
The Community Research Advisory Council (C-RAC) of the Johns Hopkins Institute for Clinical and Translational Research was established in 2009 to provide community-engaged research consultation services. In 2016–2017, C-RAC members and researchers were surveyed on their consultation experiences. Survey results and a 2019 stakeholder meeting proceeding helped redesign the consultation services. Transitioning to virtual consultations during COVID-19, the redesigning involved increasing visibility, providing consultation materials in advance, expanding member training, and effective communications. An increase in consultations from 28 (2009–2017) to 114 (2020–2022) was observed. Implementing stakeholder-researcher inputs is critical to holistic and sustained community-engaged research.
The spatial distribution of in situ sessile organisms, including those from the fossil record, provides information about life histories, such as possible dispersal and/or settlement mechanisms, and how taxa interact with one another and their local environments. At Nilpena Ediacara National Park (NENP), South Australia, the exquisite preservation and excavation of 33 fossiliferous bedding planes from the Ediacara Member of the Rawnsley Quartzite reveals in situ communities of the Ediacara Biota. Here, the spatial distributions of three relatively common taxa, Tribrachidium, Rugoconites, and Obamus, occurring on excavated surfaces were analyzed using spatial point pattern analysis. Tribrachidium have a variable spatial distribution, implying that settlement or post-settlement conditions/preferences had an effect on populations. Rugoconites display aggregation, possibly related to their reproductive methods in combination with settlement location availability at the time of dispersal and/or settlement. Additionally, post-settlement environmental controls could have affected Rugoconites on other surfaces, resulting in lower populations and densities. Both Tribrachidium and Rugoconites also commonly occur as individuals or in low numbers on a number of beds, thus constraining possible reproductive strategies and environmental/substrate preferences. The distribution of Obamus is consistent with selective settlement, aggregating near conspecifics and on substrates of mature microbial mat. This dispersal process is the first example of substrate-selective dispersal among the Ediacara Biota, thus making Obamus similar to numerous modern sessile invertebrates with similar dispersal and settlement strategies.
Despite the adversity presented by COVID-19 pandemic, it also pushed for experimenting with innovative strategies for community engagement. The Community Research Advisory Council (C-RAC) at Johns Hopkins University (JHU), is an initiative to promote community engagement in research. COVID-19 rendered it impossible for C-RAC to conduct its meetings all of which have historically been in person. We describe the experience of advancing the work of the C-RAC during COVID-19 using digital and virtual strategies. Since March 2020, C-RAC transitioned from in person to virtual meetings. The needs assessment was conducted among C-RAC members, and individualized solutions provided for a successful virtual engagement. The usual working schedule was altered to respond to COVID-19 and promote community engaged research. Attendance to C-RAC meetings before and after the transition to virtual operation increased from 69% to 76% among C-RAC members from the community. In addition, the C-RAC launched new initiatives and in eighteen months since January 2020, it conducted 50 highly rated research reviews for 20 research teams. The experience of the C-RAC demonstrates that when community needs are assessed and addressed, and technical support is provided, digital strategies can lead to greater community collaborations.
Background: Contact tracing alone is often inadequate to determine the source of healthcare personnel (HCP) COVID-19 when SARS-CoV-2 is widespread in the community. We combined whole-genome sequencing (WGS) with traditional epidemiologic analysis to investigate the frequency with which patients or other HCP with symptomatic COVID-19 acted as the source of HCP infection at a large tertiary-care center early in the pandemic. Methods: Cohort samples were selected from patients and HCP with PCR-positive SARS-CoV-2 infection from a period with complete retention of samples (March 14, 2021–April 10, 2020) at Rush University Medical Center, a 664-bed hospital in Chicago, Illinois. During this period, testing was limited to symptomatic patients and HCP. Recommended respiratory equipment for HCP evolved under guidance, including a 19-day period when medical face masks were recommended for COVID-19 care except for aerosol-generating procedures. Viral RNA was extracted and sequenced (NovaSeq, Illumina) from remnant nasopharyngeal swab samples in M4RT viral transport medium. Genomes with >90% coverage underwent cluster detection using a 2 single-nucleotide variant genetic distance cutoff. Genomic clusters were independently evaluated for valid epidemiologic links by 2 infectious diseases physicians (with a third adjudicator) using metadata extracted from the electronic medical record and according to predetermined criteria (Table 1). Results: In total, 1,031 SARS-CoV-2 sequences were analyzed, identifying 49 genomic clusters with HCP (median, 8; range, 2–43 members per cluster; total, 268 patients and 115 HCP) (Fig. 1). Also, 20,190 flowsheet activities were documented for cohort HCP and patient interactions, including 686 instances in which a cohort HCP contributed to a cohort patient’s chart. Most HCP infections were considered not healthcare associated (88 of 115, 76.5%). We did not identify any strong linkages for patient-to-HCP transmission. Moreover, 13 HCP cases (11.3%) were attributed to patient source (weak linkage). Also, 14 HCP cases (12.2%) were attributed to HCP source (11 strong and 3 weak linkages). Weak linkages were due to lack of epidemiologic data for HCP location, particularly nonclinical staff (eg, an environmental service worker who lacked location documentation to rule out patient-specific contact). Agreement for epidemiologic linkage between the 2 evaluators was high (κ, 0.91). Conclusions: Using genomic and epidemiologic data, we found that most HCP COVID-19 infections were not healthcare associated. We found weak evidence to support symptomatic patient-to-HCP transmission of SARS-CoV-2 and stronger evidence for HCP-to-HCP transmission. Large genomic clusters without plausible epidemiologic links were identified, reflecting the limited utility of genomic surveillance alone to characterize chains of transmission of SARS-CoV-2 during extensive community spread.
This study aimed to understand stigma in relation to people living with dementia in São Paulo, Brazil. A critical narrative inquiry methodology was used. Home-based semi-structured interviews were conducted between January and March 2020 with six people living with dementia and 15 family carers. Data analysis was conducted using inductive and deductive techniques. The latter was informed by Link and Phelan's sociological theory of stigma. We found that dementia was commonly viewed by people living with dementia as part of ageing and carers reported low levels of knowledge and awareness about the condition. To avoid negative reactions from people, people living with dementia managed the negative views of dementia by minimising and normalising the condition, by expressing their ability to live an active life, and by emphasising the positive impacts of dementia in their lives. Fear of negative reactions appeared to lead to a selective disclosure of their diagnosis. Among carers, stigmatising attitudes coincided with a strong willingness to provide good care, to protect the person cared for, as well as to understand and validate their own caring experiences, rather than to cause any harm. In doing so, however, carers ended up depersonalising and infantilising people living with dementia, underestimating their capacities, demanding ‘obedience’ and restricting the person's freedom. There is a need to increase awareness about dementia and to provide support and training on person-centred and ethical care for carers in Brazil.
While research on the health and wellbeing of older lesbian, gay and bisexual adults is gradually expanding, research on older trans and gender non-conforming (TGNC) adults lags behind. Current scholarship about this group raises important questions about the intersection of ageing and gender identity for enhancing care and support for older TGNC adults and the lack of preparedness of health and social professionals for meeting these needs. In this paper, we examine the accounts of 22 TGNC individuals (50–74 years) on the topic of ageing and unpack their concerns for and expectations of later life. We present qualitative findings from a study of gender identity, ageing and care, based in Wales, United Kingdom. Data were generated from two-part interviews with each participant. Four key themes are identified: (a) facilitative factors for transitioning in mid- to later life; (b) growing older as a new lease of life; (c) growing older: regrets, delays and uncertainties; and (d) ambivalent expectations of social care services. We argue that growing older as TGNC can be experienced across a multitude of standpoints, ranging from a new lease of life to a time of regret and uncertainty. We critically discuss emergent notions of trans time, precarity and uncertainty running across participants’ accounts, and the implications for enhancing recognition of gender non-conformity and gender identity in social gerontology.
We address two main issues: the distinction between time-constrained and spatially constrained tasks, and the separable A and W effects on movement time (MT) in spatially-constrained tasks. We consider MT and 3-D kinematic data from human adults pointing to targets in human-computer interaction. These are better fit by Welford's (1968) two-part model, than Fitts' (1954; Fitts & Peterson 1964) ID model. We identify theoretical and practical implications.
Apolipoprotein E (APOE) E4 is the main genetic risk factor for Alzheimer’s disease (AD). Due to the consistent association, there is interest as to whether E4 influences the risk of other neurodegenerative diseases. Further, there is a constant search for other genetic biomarkers contributing to these phenotypes, such as microtubule-associated protein tau (MAPT) haplotypes. Here, participants from the Ontario Neurodegenerative Disease Research Initiative were genotyped to investigate whether the APOE E4 allele or MAPT H1 haplotype are associated with five neurodegenerative diseases: (1) AD and mild cognitive impairment (MCI), (2) amyotrophic lateral sclerosis, (3) frontotemporal dementia (FTD), (4) Parkinson’s disease, and (5) vascular cognitive impairment.
Methods:
Genotypes were defined for their respective APOE allele and MAPT haplotype calls for each participant, and logistic regression analyses were performed to identify the associations with the presentations of neurodegenerative diseases.
Results:
Our work confirmed the association of the E4 allele with a dose-dependent increased presentation of AD, and an association between the E4 allele alone and MCI; however, the other four diseases were not associated with E4. Further, the APOE E2 allele was associated with decreased presentation of both AD and MCI. No associations were identified between MAPT haplotype and the neurodegenerative disease cohorts; but following subtyping of the FTD cohort, the H1 haplotype was significantly associated with progressive supranuclear palsy.
Conclusion:
This is the first study to concurrently analyze the association of APOE isoforms and MAPT haplotypes with five neurodegenerative diseases using consistent enrollment criteria and broad phenotypic analysis.
The third edition of Inside Lawyers' Ethics offers an engaging and practical examination of the moral and ethical dilemmas that legal professionals may encounter in a rapidly changing professional environment. The text provides comprehensive coverage and analysis of general philosophical approaches to morality as well as the legal frameworks which govern ethical decision-making and practice. This new edition has been thoroughly updated and provides in-depth coverage of the Australian Solicitors' Conduct Rules (ASCR) to enable readers to successfully understand, analyse and apply guiding ethical frameworks. Case studies and discussion questions in each chapter provide practical examples from case law, legal practice and research to illustrate common challenges and explain how ethical and moral principles can be applied to a variety of common scenarios. Written by leading academics in the field, this essential text equips readers with the skills to enact ethical behaviours and confidently confront common ethical challenges in their everyday practice.
Inside Lawyers' Ethics is a lively and practical values-based analysis of the moral dilemmas that lawyers face. It gives lawyers the confidence to understand and actively improve their ethical priorities and behaviour when confronted with major ethical challenges. It identifies the applicable law and conduct rules and analyses them in the context of four different types of ethical lawyering: zealous advocacy, responsible lawyering, moral activism and the ethics of care. This new edition is fully updated, with a new chapter on confidentiality and new case studies and review questions. This edition also contains a self-assessment instrument designed to allow readers to recognise the type of lawyering that most appeals to them. Inside Lawyers' Ethics promotes self-awareness and offers a positive and enriching approach to problem solving, rather than one based on the 'don't get caught' principle. It is essential reading for students of law and newly qualified legal practitioners.
Clients are more likely to complain about their lawyers’ fees and costs than any other issue, and even the most conscientious lawyers have trouble explaining fees to clients and controlling their growth. Successful lawyers are effective in managing the communication process so that costs are paid on time, but that communication has many elements and some common pitfalls. Typical complaints include that the lawyer has failed to make proper disclosure of likely costs at the commencement of the matter, failed to provide a written bill, failed to provide an itemised bill when requested by the client, failed to provide an updated estimate, or has charged for the preparation of an itemised bill (even though clients have a right to request one). Deliberate ‘gross’ over-charging also features prominently among client complaints, as does the withdrawal of costs from a client's trust account without their permission, or the deduction of fees in the absence of a proper bill. In all these matters, small individual clients are especially vulnerable. Corporate clients are in a better position to complain effectively about costs because of their greater capacity to deny ongoing work to a lawyer who is seen to be price-gouging. Not surprisingly, clients complain about lawyers who have the temerity to charge costs for litigated matters that amount to more than the amount actually recovered in the litigation. Also featuring prominently among client complaints about lawyers are complaints about excessive hourly billing rates and exploitation of ‘no-win, no-fee’ agreements. There is considerable potential for clients to think that ‘no-win, no-fee’ means exactly that, whereas it is clear that a client's disbursements (out of pocket expenses) and, as we outline below in the section ‘Fees and costs in litigation’, the reasonable legal costs of the other party will generally be paid by a losing client. Clients routinely complain that they have been promised that they will incur no fees unless they win, but find themselves losing and either having to pay the costs of the other side or disagreeing with their lawyer about whether there has been a ‘win’.
One Queensland lawyer was suspended for 12 months for gross over-charging for billing a ‘no-win, no-fee’ client $300 per hour plus a premium of 25% for all work done by any employee of the firm, from partner to paralegal to secretary.
As we saw in the previous chapter, the different roles of criminal defence and prosecution lawyers are clearly delineated by the very nature of a criminal trial as a public forum for determining guilt and innocence and upholding the Rule of Law. In civil litigation, however, the nature of the process and the roles and responsibilities of the lawyers are more ambiguous. Lawyers play a number of roles in civil matters which can range from aggressive advocacy in fully litigated civil trials to deal-maker and representative in negotiating the legal structure of multi-party collaborative commercial projects. Lawyers may act on behalf of clients in formal mediation or informal negotiations to settle civil matters. They may also provide advice, guidance and practical help in pro-actively managing and structuring commercial, domestic or governmental transactions and affairs to avoid disputes.
There is a public interest in maintaining the fairness and justice of the court system and the legal decisions emanating from that system. Lawyers therefore have an overriding duty to the administration of justice. In recent times it is also increasingly recognised that there is a public interest in the encouragement of efficient and efficacious dispute resolution without recourse to court where possible. Therefore, even in private negotiations and alternative dispute resolution, lawyers have a duty to the administration of justice, grounded in responsible lawyering.
Lawyers are also, however, representatives of their clients who have a private interest in having disputes concluded in certain ways. When a person needs to use a lawyer, they are often in the midst of conflict and not always at their most altruistic or rational. The work that clients ask their lawyers to do may be aimed at cutting across the interests and positions of other people. People need lawyers precisely because of the conflicts we face as we live together in society. Surveys show that people tend to be critical of lawyers in general but very favourable towards their own lawyer: they condemn lawyers for doing for others what they praise them for doing for themselves – being adversarial advocates.
The profession has traditionally seen it as a cornerstone of adversarial advocacy that lawyers serve each client's interest loyally, confidentially and carefully. As we saw in Chapter 4, the touchstone of lawyers’ professional obligations of devoted service to their clients is the trilogy of duties – loyalty, confidentiality and care; and the most strict and onerous rules in the law of lawyering relate to these duties. This chapter is concerned with the first of those duties – loyalty.
The duty of loyalty requires lawyers to avoid situations involving a conflict of interest between a lawyer's personal interest and their duty to a client; or, a conflict of duties owed to two or more clients. It also requires lawyers to refrain from using their relationship with the client as a means of making any personal gain; and they must fully disclose to their client any conflicts of interest or personal gains that do arise. These obligations apply not just to the individual lawyer but to the whole firm: if one lawyer cannot act for a potential client because of a conflict of interest, then usually the whole firm cannot act. These are ‘fiduciary’ obligations set out and enforceable in the law of equity and also reinforced in professional conduct rules and disciplinary decisions. In addition to being sued by their clients for breach of these obligations at general law, lawyers can also be disciplined for misconduct.
The duty of loyalty is a virtue ethics concept and can be based in either or both adversarial advocacy and responsible lawyering. Adversarial advocacy assumes that clients need to be able to trust their lawyers to provide advice and represent them in the legal system completely uninfluenced by any concern other than the client's interests. A narrow adversarial advocacy conception of the duty of loyalty would see the client's interest as the touchstone of the duty. This means that as long as the client's interests are not actually harmed, then it might be possible to ‘cure’ a potential conflict through measures such as client consent or information barriers (discussed further below). On an adversarial advocacy approach, the duty of loyalty also might not survive the ending of the lawyer-client relationship to the extent that the lawyer is no longer obligated to further the client's interests.