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On the upper reaches of the Tigris and Euphrates, archaeologists encounter evidence that challenges conventional understandings of early state formation as a transition from ‘small-scale, egalitarian’ to ‘large-scale, stratified’ societies. One such location is the Early Bronze Age cemetery of Başur Höyük, which presents evidence of grand funerary rituals—including ‘retainer burials’ and spectacular deposits of metallic wealth—in an otherwise small-scale, egalitarian setting. A further, puzzling feature of this cemetery is the preponderance of teenagers in the richest tombs. Here we describe the combined results of archaeological and anthropological analysis at Başur Höyük, including ancient DNA, and consider the challenges they pose to traditional accounts of early state formation.
The current study characterizes the attenuation of instabilities in steady and unsteady shear layers by investigating shear-thinning flows downstream of a confined axisymmetric sudden expansion. Flow fields were captured using particle image velocimetry. Tested fluids exhibited approximate power-law indices of 1, 0.81, 0.61 and 0.47 and measurements were performed at mean throat-based Reynolds numbers of ${Re_m} = 4800$ and 14 400. Unsteady flows were tested at a Strouhal number and amplitude-to-mean velocity ratio of $St = 0.15$ and $\lambda = 0.95$, respectively. For unsteady shear layers, shear-layer roll-up regardless of shear-thinning strength was evidenced by collapse of average circulation over time. For steady shear layers, consistent shear-layer behaviour regardless of shear-thinning strength was evidenced by similar shear-layer trajectories and by growth rates in vorticity thickness. However, vorticity fields of the unsteady and steady shear layers, standard deviations of shear-layer trajectory, thickness of steady shear layers and Reynolds shear-stress spectra of the steady shear layers reveal an attenuation of shear-layer instabilities not captured by Reynolds number. Specifically, shear-layer instabilities exhibit increased diffusion with increasing shear-thinning strength and, in the case of steady shear layers, shear-thinning strength is shown to promote shear-layer stabilization. Also, evidenced by vorticity fields and through Reynolds shear-stress spectra, instabilities frequently coalesce into large rollers, a result that would suggest the presence of an inverse eddy cascade. The behaviour of shear-thinning fluids is shown to stabilize shear layers through attenuating shear-layer instabilities, complementing observations from previous studies showing how shear-thinning fluids promote turbulence in the dominant flow direction.
Patients with Fontan failure are high-risk candidates for heart transplantation and other advanced therapies. Understanding the outcomes following initial heart failure consultation can help define appropriate timing of referral for advanced heart failure care.
Methods:
This is a survey study of heart failure providers seeing any Fontan patient for initial heart failure care. Part 1 of the survey captured data on clinical characteristics at the time of heart failure consultation, and Part 2, completed 30 days later, captured outcomes (death, transplant evaluation outcome, and other interventions). Patients were classified as “too late” (death or declined for transplant due to being too sick) and/or “care escalation” (ventricular assist device implanted, inotrope initiated, and/or listed for transplant), within 30 days. “Late referral” was defined as those referred too late and/or had care escalation.
Results:
Between 7/2020 and 7/2022, 77 Fontan patients (52% inpatient) had an initial heart failure consultation. Ten per cent were referred too late (6 were too sick for heart transplantation with one subsequent death, and two others died without heart transplantation evaluation, within 30 days), and 36% had care escalation (21 listed ± 5 ventricular assist device implanted ± 6 inotrope initiated). Overall, 42% were late referrals. Heart failure consultation < 1 year after Fontan surgery was strongly associated with late referral (OR 6.2, 95% CI 1.8–21.5, p=0.004).
Conclusions:
Over 40% of Fontan patients seen for an initial heart failure consultation were late referrals, with 10% dying or being declined for transplant within a month of consultation. Earlier referral, particularly for those with heart failure soon after Fontan surgery, should be encouraged.
The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and Pediatric Heart Transplant Society (PHTS) convened a working group at the beginning of 2020 during the COVID-19 pandemic, with the aim of using telehealth as an alternative medium to provide quality care to a high-acuity paediatric population receiving advanced cardiac therapies. An algorithm was developed to determine appropriateness, educational handouts were developed for both patients and providers, and post-visit surveys were collected. Telehealth was found to be a viable modality for health care delivery in the paediatric heart failure and transplant population and has promising application in the continuity of follow-up, medication titration, and patient education/counselling domains.
For G a profinite group, we construct an equivalence between rational G-Mackey functors and a certain full subcategory of G-sheaves over the space of closed subgroups of G called Weyl-G-sheaves. This subcategory consists of those sheaves whose stalk over a subgroup K is K-fixed.
This extends the classification of rational G-Mackey functors for finite G of Thévenaz and Webb, and Greenlees and May to a new class of examples. Moreover, this equivalence is instrumental in the classification of rational G-spectra for profinite G, as given in the second author’s thesis.
Citizens' everyday conduct is shaped by governmental action, yet there is much evidence that both front-line public service staff and service users can sometimes act in ways that modify or disrupt intended policy outcomes. This book presents a highly original examination of how policy objectives can be 'subverted' through the actions of citizens.
To assist hospitals in reducing Clostridioides difficile infections (CDI), the Centers for Disease Control and Prevention (CDC) implemented a collaborative using the CDC CDI prevention strategies and the Targeted Assessment for Prevention (TAP) Strategy as foundational frameworks.
Setting:
Acute-care hospitals.
Methods:
We invited 400 hospitals with the highest cumulative attributable differences (CADs) to the 12-month collaborative, with monthly webinars, coaching calls, and deployment of the CDC CDI TAP facility assessments. Infection prevention barriers, gaps identified, and interventions implemented were qualitatively coded by categorizing them to respective CDI prevention strategies. Standardized infection ratios (SIRs) were reviewed to measure outcomes.
Results:
Overall, 76 hospitals participated, most often reporting CDI testing as their greatest barrier to achieving reduction (61%). In total, 5,673 TAP assessments were collected across 46 (61%) hospitals. Most hospitals (98%) identified at least 1 gap related to testing and at least 1 gap related to infrastructure to support prevention. Among 14 follow-up hospitals, 64% implemented interventions related to infrastructure to support prevention (eg, establishing champions, reviewing individual CDIs) and 86% implemented testing interventions (eg, 2-step testing, testing algorithms). The SIR decrease between the pre-collaborative and post-collaborative periods was significant among participants (16.7%; P < .001) but less than that among nonparticipants (25.1%; P < .001).
Conclusions:
This article describes gaps identified and interventions implemented during a comprehensive CDI prevention collaborative in targeted hospitals, highlighting potential future areas of focus for CDI prevention efforts as well as reported challenges and barriers to prevention of one of the most common healthcare-associated infections affecting hospitals and patients nationwide.
Title VI of the Civil Rights Act of 1964 and its implementing regulations prohibit federally-funded educational institutions and healthcare centers from engaging in disparate impact discrimination “on the ground of race, color, or national origin” in all of their operations.
A supply disruption alert in 2020, now rescinded, notified UK prescribers of the planned discontinuation of Priadel® (lithium carbonate) tablets. This service evaluation explored lithium dose and plasma levels before and after the switching of lithium brands, in order to determine the interchangeability of different brands of lithium from a pharmacokinetic perspective.
Results
Data on the treatment of 37 patients switched from Priadel® tablets were analysed. Switching to Camcolit® controlled-release tablets at the same dose did not result in meaningful differences in plasma lithium levels. Dose adjustment and known or suspected poor medication adherence were associated with greater variability in plasma lithium levels on switching brands.
Clinical implications
For comparable pre- and post-switch doses in adherent patients, the most common brands of lithium carbonate appear to produce similar plasma lithium levels. British National Formulary guidance relating to switching lithium brands may be unnecessarily complex.
Children with conduct problems and high callous-unemotional (CP+CU) traits are characterized by dampened emotional responding, limiting their ability for affective empathy and impacting the development of prosocial behaviors. However, research documenting this dampening in young children is sparse and findings vary, with attachment-related stimuli hypothesized to ameliorate deficits in emotional responding. Here we test emotional responsiveness across various emotion-eliciting stimuli using multiple measures of emotional responsiveness (behavioral, physiological, self-reported) and attention, in young children aged 2–8 years (M age = 5.37), with CP+CU traits (CP+CU; n = 36), CPs and low CU traits (CP−CU; n = 82) and a community control sample (CC; n = 27). We found no evidence that attachment-related stimulus ameliorated deficits in emotional responding. Rather, at a group level we found a consistent pattern of reduced responding across all independent measures of responsiveness for children with CP+CU compared to the CC group. Few differences were found between CP+CU and CP−CU groups. When independent measures were standardized and included in a regression model predicting to CU trait score, higher CU traits were associated with reduced emotional responding, demonstrating the importance of multimodal measurement of emotional responsiveness when investigating the impact of CU traits in young children.
For an equivariant commutative ring spectrum R, ?0R has algebraic structure reflecting the presence of both additive transfers and multiplicative norms. The additive structure gives rise to a Mackey functor and the multiplicative structure yields the additional structure of a Tambara functor. If R is an N? ring spectrum in the category of genuine G-spectra, then all possible additive transfers are present and ?0R has the structure of an incomplete Tambara functor. However, if R is an N? ring spectrum in a category of incomplete G-spectra, the situation is more subtle. In this chapter, we study the algebraic theory of Tambara structures on incomplete Mackey functors, which we call bi-incomplete Tambara functors. Just as incomplete Tambara functors have compatibility conditions that control which systems of norms are possible, bi-incomplete Tambara functors have algebraic constraints arising from the possible interactions of transfers and norms. We give a complete description of the possible interactions between the additive and multiplicative structures.
We survey some methods developed in a series of papers, for classifying localising subcategories of tensor triangulated categories. We illustrate these methods by proving a new theorem, providing such a classification in the case of the stable module category of a unipotent finite supergroup scheme.
In their work on the period map and the dualising sheaf for Lubin–Tate space, Gross and the second author wrote down an equivalence between the Spanier–Whitehead and Brown–Comenetz duals of certain type n-complexes in the K(n)-local category at large primes. In the culture of the time, these results were accessible to educated readers, but this seems no longer to be the case; therefore, in this note we give the details. Because we are at large primes, the key result is algebraic: in the Picard group of Lubin–Tate space, two important invertible sheaves become isomorphic modulo p.
We give conditions on a monoidal model category M and on a set of maps C so that the Bousfield localisation of M with respect to C preserves the structure of algebras over various operads. This problem was motivated by an example that demonstrates that, for the model category of equivariant spectra, preservation does not come for free. We discuss this example in detail and provide a general theorem regarding when localisation preserves P-algebra structure for an arbitrary operad P. We characterise the localisations that respect monoidal structure and prove that all such localisations preserve algebras over cofibrant operads. As a special case we recover numerous classical theorems about preservation of algebraic structure under localisation, in the context of spaces, spectra, chain complexes, and equivariant spectra. To demonstrate our preservation result for non-cofibrant operads, we work out when localisation preserves commutative monoids and the commutative monoid axiom. Finally, we provide conditions so that localisation preserves the monoid axiom.
In this note, we construct a higher-dimensional version of the chromatic fracture square. We then categorify the resulting chromatic fracture cubes obtaining a decomposition of the category of E(n)-local spectra into monochromatic pieces.
We survey several notions of Mackey functors and biset functors found in the literature and prove some old and new theorems comparing them. While little here will surprise the experts, we draw a conceptual and unified picture by making systematic use of finite groupoids. This provides a ‘road map’ for the various approaches to the axiomatic representation theory of finite groups, as well as some details that are hard to find in the literature.