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The funding of primary care is subject to intense debate internationally. Three main funding models predominate: capitation, pay-for-performance, and fee-for-service. A number of systematic reviews regarding the effect of primary care funding structures have been published, but not synthesized through an equity lens. Given the urgent need for evaluating funding models and addressing inequalities, a reliable, synthesized evidence base concerning the effects of funding on inequalities is imperative.
Aims:
This umbrella review aims to systematically evaluate all systematic reviews available on the effect of different primary care funding models in high-income countries on inequalities in funding, access, outcomes, or experience from inception until 2024.
Methods:
Three databases (MEDLINE, EMBASE, Cochrane) and a machine learning living evidence map were searched. Abstracts and titles were double screened, before two authors independently screened full texts, extracted data, and performed quality assessments utilizing the AMSTAR2 tool.
Findings:
The search identified 2480 unique articles, of which 14 were included in the final review. Only one review compared reimbursement systems; capitation systems were more equitable between ethnic groups compared to pay-for-performance in terms of primary care access, continuity, and quality. Twelve reviews reviewed the impact of the introduction of pay-for-performance models, predominantly focusing on the Quality and Outcomes Framework (QOF) in the UK. Synthesized findings suggest that QOF’s introduction coincided with reduced socioeconomic health inequalities in the UK overall, but not in Scotland. Overall, inequalities in age narrowed, but inequalities measured by sex widened. One review found evidence that targeting funding for minority groups, with poorer health, was effective. A further review found that introducing privately provided general practices in Sweden and allowing patients to choose these over public-owned options generally benefitted those with higher income and lower health needs. We identify a range of gaps in the literature, which should inform future research.
Preliminary evidence suggests that a ketogenic diet may be effective for bipolar disorder.
Aims
To assess the impact of a ketogenic diet in bipolar disorder on clinical, metabolic and magnetic resonance spectroscopy outcomes.
Method
Euthymic individuals with bipolar disorder (N = 27) were recruited to a 6- to 8-week single-arm open pilot study of a modified ketogenic diet. Clinical, metabolic and MRS measures were assessed before and after the intervention.
Results
Of 27 recruited participants, 26 began and 20 completed the ketogenic diet. For participants completing the intervention, mean body weight fell by 4.2 kg (P < 0.001), mean body mass index fell by 1.5 kg/m2 (P < 0.001) and mean systolic blood pressure fell by 7.4 mmHg (P < 0.041). The euthymic participants had average baseline and follow-up assessments consistent with them being in the euthymic range with no statistically significant changes in Affective Lability Scale-18, Beck Depression Inventory and Young Mania Rating Scale. In participants providing reliable daily ecological momentary assessment data (n = 14), there was a positive correlation between daily ketone levels and self-rated mood (r = 0.21, P < 0.001) and energy (r = 0.19 P < 0.001), and an inverse correlation between ketone levels and both impulsivity (r = −0.30, P < 0.001) and anxiety (r = −0.19, P < 0.001). From the MRS measurements, brain glutamate plus glutamine concentration decreased by 11.6% in the anterior cingulate cortex (P = 0.025) and fell by 13.6% in the posterior cingulate cortex (P = <0.001).
Conclusions
These findings suggest that a ketogenic diet may be clinically useful in bipolar disorder, for both mental health and metabolic outcomes. Replication and randomised controlled trials are now warranted.
Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date.
Aims
To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder.
Method
Euthymic individuals with bipolar disorder were recruited to a 6–8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198.
Results
Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6–8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication).
Conclusions
The recruitment and retention of euthymic individuals with bipolar disorder to a 6–8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.
Horseweed [Conyza canadensis (L.) Cronquist] grows in one of two distinct growth phenotypes, “rosette” and “upright” growth types, and they have recently been observed co-occurring in Michigan fields. Previous research found that upright plants from two glyphosate-resistant populations were 3- and 4-fold less sensitive to glyphosate than their rosette siblings. Further experiments were conducted to investigate whether differential glyphosate sensitivity of the growth types was due to glyphosate retention, absorption, or translocation. The total amount of glyphosate retained on the C. canadensis leaf surface was similar for both growth types; however, on a per-weight and per-area bases, the upright growth type retained 21% and 18% less glyphosate, respectively. Glyphosate absorption was up to 85% at 168 h after treatment (HAT), and was not different between the rosette and upright growth types or between the susceptible (S) and resistant (R) biotypes. Additionally, there was no difference in translocation between the two growth types within each biotype at any time point. Interestingly, at 168 HAT, [14C]glyphosate translocation was higher in the S rosette compared with the two growth types from the R biotype; however, the S upright type was similar to both R growth types. Thus, glyphosate resistance in the R biotype may be due to an alternative mechanism rather than impaired translocation, which has been cited as the primary mechanism of glyphosate resistance in C. canadensis. These results suggest that reduced glyphosate retention on a per-weight and per-area bases of the upright growth type may contribute to increased glyphosate tolerance due to a diluted concentration of glyphosate in the plant. However, another factor is likely related to the mechanism of resistance within the R biotype, which is contributing to a 3-fold difference in glyphosate sensitivity between the two growth types, such as alterations in EPSPS gene expression or changes in undescribed metabolism genes.
Despite an elevated risk of psychopathology stemming from COVID-19-related stress, many essential workers stigmatise and avoid psychiatric care. This randomised controlled trial was designed to compare five versions of a social-contact-based brief video intervention for essential workers, differing by protagonist gender and race/ethnicity.
Aims
We examined intervention efficacy on treatment-related stigma (‘stigma’) and openness to seeking treatment (‘openness’), especially among workers who had not received prior mental healthcare. We assessed effectiveness and whether viewer/protagonist demographic concordance heightened effectiveness.
Method
Essential workers (N = 2734) randomly viewed a control video or brief video of an actor portraying an essential worker describing hardships, COVID-related anxiety and depression, and psychotherapy benefits. Five video versions (Black/Latinx/White and male/female) followed an identical 3 min script. Half the intervention group participants rewatched their video 14 days later. Stigma and openness were assessed at baseline, post-intervention, and at 14- and 30-day follow-ups. Trial registration: NCT04964570.
Results
All video intervention groups reported immediately decreased stigma (P < 0.0001; Cohen's d = 0.10) and increased openness (P < 0.0001; d = 0.23). The initial increase in openness was largely maintained in the repeated-video group at day 14 (P < 0.0001; d = 0.18), particularly among viewers without history of psychiatric treatment (P < 0.0001; d = 0.32). Increases were not sustained at follow-up. Female participants viewing a female protagonist and Black participants viewing a Black protagonist demonstrated greater openness than other demographic pairings.
Conclusions
Brief video-based interventions improved immediate stigma and openness. Greater effects among female and Black individuals viewing demographically matched protagonists emphasise the value of tailored interventions, especially for socially oppressed groups. This easily disseminated intervention may proactively increase care-seeking, encouraging treatment among workers in need. Future studies should examine intervention mechanisms and whether linking referrals to psychiatric services generates treatment-seeking.
To describe the cumulative seroprevalence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antibodies during the coronavirus disease 2019 (COVID-19) pandemic among employees of a large pediatric healthcare system.
Design, setting, and participants:
Prospective observational cohort study open to adult employees at the Children’s Hospital of Philadelphia, conducted April 20–December 17, 2020.
Methods:
Employees were recruited starting with high-risk exposure groups, utilizing e-mails, flyers, and announcements at virtual town hall meetings. At baseline, 1 month, 2 months, and 6 months, participants reported occupational and community exposures and gave a blood sample for SARS-CoV-2 antibody measurement by enzyme-linked immunosorbent assays (ELISAs). A post hoc Cox proportional hazards regression model was performed to identify factors associated with increased risk for seropositivity.
Results:
In total, 1,740 employees were enrolled. At 6 months, the cumulative seroprevalence was 5.3%, which was below estimated community point seroprevalence. Seroprevalence was 5.8% among employees who provided direct care and was 3.4% among employees who did not perform direct patient care. Most participants who were seropositive at baseline remained positive at follow-up assessments. In a post hoc analysis, direct patient care (hazard ratio [HR], 1.95; 95% confidence interval [CI], 1.03–3.68), Black race (HR, 2.70; 95% CI, 1.24–5.87), and exposure to a confirmed case in a nonhealthcare setting (HR, 4.32; 95% CI, 2.71–6.88) were associated with statistically significant increased risk for seropositivity.
Conclusions:
Employee SARS-CoV-2 seroprevalence rates remained below the point-prevalence rates of the surrounding community. Provision of direct patient care, Black race, and exposure to a confirmed case in a nonhealthcare setting conferred increased risk. These data can inform occupational protection measures to maximize protection of employees within the workplace during future COVID-19 waves or other epidemics.
To describe outcomes of acute coronavirus disease 2019 in paediatric and young adult patients with underlying cardiac disease and evaluate the association between cardiac risk factors and hospitalisation.
Study design
We conducted a retrospective single-institution review of patients with known cardiac disease and positive severe acute respiratory syndrome coronavirus 2 RT-PCR from 1 March, 2020 to 30 November, 2020. Extracardiac comorbidities and cardiac risk factors were compared between those admitted for coronavirus disease 2019 illness and the rest of the cohort using univariate analysis.
Results
Forty-two patients with a mean age of 7.7 ± 6.7 years were identified. Six were 18 years of age or more with the oldest being 22 years of age. Seventy-six percent were Hispanic. The most common cardiac diagnoses were repaired cyanotic (n = 7, 16.6%) and palliated single ventricle (n = 7, 16.6%) congenital heart disease. Fourteen patients (33.3%) had underlying syndromes or chromosomal anomalies, nine (21%) had chronic pulmonary disease and eight (19%) were immunosuppressed. Nineteen patients (47.6%) reported no symptoms. Sixteen (38.1%) reported only mild symptoms. Six patients (14.3%) were admitted to the hospital for acute coronavirus disease 2019 illness. Noncardiac comorbidities were associated with an increased risk of hospitalisation (p = 0.02), particularly chronic pulmonary disease (p = 0.01) and baseline supplemental oxygen requirement (p = 0.007). None of the single ventricle patients who tested positive required admission.
Conclusions
Hospitalisations for coronavirus disease 2019 were rare among children and young adults with underlying cardiac disease. Extracardiac comorbidities like pulmonary disease were associated with increased risk of hospitalisation while cardiac risk factors were not.
Protest is ubiquitous in contemporary societies, as is illustrated by any review of recent news headlines. Tarrow and Meyer (1998) refer to the proliferation of protest and its diffusion into everyday life as characteristics of "the social movement society." Social networks are integral to understanding social movement processes. This chapter provides a broad overview of the SNA methodological toolkit, with a focus on ego-networks, so that social movements scholars better understand how networks shape social movement recruitment and support, communication, and social-political influence. The chapter is structured as followed. First, we provide a contextual overview of research on networks, collective action and social movements that underlines the importance of SNA approaches to social movement research. Second, we introduce a set of standard ego-network approaches to social movements and discuss some of the attendant challenges of these approaches. Third, we discuss less well-established qualitative and mixed-methods network approaches to social movements research. Fourth, we describe and discuss some consideration relevant to conducting longitudinal social network analysis, and modeling network dynamics. Finally, we discuss virtual networks as sources of social movements data collection and analysis.
In its earliest stages the macroscopic properties of a human embryo are merely those of a few-celled organism, not so very different from (say) a fly embryo. If all goes well, however, it will eventually develop into a human infant. Expectation of such future development leads to the absolutist view that from the moment of conception the zygote has the same moral status as an infant. When the absolutist view is based on this expectation, I shall say it is based on a potentialist intuition that sees fetal development as the unfolding of a pre-established essence. This intuition was expressed by a Tennessee judge dealing with a custody case concerning frozen embryos, who claimed that ‘the entire constitution of the man is clearly, unequivocally spelled-out, including arms, legs, nervous system and the like ....’ Singer and Dawson put the potentialist picture (with which they disagree) in these terms: ‘The development of the embryo inside the female body can be seen as a mere unfolding of a potential that is inherent in it.’
The forests of the north-east USA were once home to the wolf Canis lupus, a species that played an important role in the ecology of this region. However, wolves were eradicated from the region more than a century ago, altering the species composition of the landscape and driving cascading changes in this ecosystem. Outdoor recreation is a major component of the economy of this region, and outdoor recreationists, including the hunting community, have a strong influence over decision-making related to policies on natural resources. Given their powerful position, hunters are important stakeholders whose views need to be taken into account when designing policies related to wildlife, in particular in relation to a controversial species such as the wolf. In this study, through expert interviews and an online survey, we gained a deeper understanding of the attitudes of hunters towards wolves, and how these attitudes could affect any future reintroduction programme or natural movement of wolves into the state. We found that the majority of hunters hold a suite of negative attitudes towards wolves, their role in the landscape and their potential impact on the region. However, for hunters who were able to recognize the ecological roles of wolves, these negative attitudes were mostly reversed.
Highly anomalous platinum-group element (PGE) concentrations in the podiform chromitites at the Cliff and Harold's Grave localities in the Shetland ophiolite complex have been well documented previously. The focus of this study is alluvial platinum-group minerals (PGM) located in small streams that drain from the PGE-rich chromitites. The placer PGM assemblage at Cliff is dominated by Pt-arsenides (64%) and Pd-antimonides (17%), with less irarsite–hollingworthite (11%) and minor Pd-sulfides, Pt–Pd–Cu and Pt–Fe alloys and laurite. Gold also occurs with the PGM. Alluvial PGM have average sizes of 20 µm × 60 µm, with sperrylite the largest grain identified at 110 µm in diameter, matching the range reported for the primary PGM in the source rocks. The placer assemblage contains more Pt-bearing and less Pd-bearing PGM compared with the rocks. The more resistant sperrylite and irarsite–hollingworthite grains which are often euhedral become more rounded further downstream whereas the less resistant Pd-antimonides which are commonly subhedral may become striated and etched. Less stable phases such as Pt- and Pd-oxides and other Ni-Cu-bearing phases located in the rocks (i.e. Ru-pentlandite, PtCu, Pd–Cu alloy) are absent in the placer assemblage. Also the scarce PGM (PdHg, Rh- and Ir-Sb) and Os in the rocks are absent. At Harold's Grave only three alluvial PGM (laurite, Ir, Os) and Au were recovered reflecting the limited release of IPGM from chromite grains in the rocks. In this cold climate with high rainfall, where erosion dominates over weathering, the PGM appear to have been derived directly from the erosion of the adjacent PGE-rich source rocks and there is little evidence of in situ growth of any newly formed PGM. Only the presence of dendritic pure Au and Pd-, Cu-bearing Au covers on the surface of primary minerals may indicate some local reprecipitation of these metals in the surficial conditions.
Inclusions of platinum-group minerals (PGM) within alluvial isoferroplatinum nuggets from the Freetown Peninsula, Sierra Leone, are aligned with their shape determined by the structure of their host. The edges of the majority of the inclusions lie at 0°, 45° or 90° to external crystal edges of the nugget which shows that the inclusions are not randomly oriented earlier minerals incorporated within their host. The inclusions are later infills, probably formed at the surface of the nugget during growth and subsequently enclosed by the growing nugget. PGM on the present surface of the nugget represent the last stage of this partnership. A single nugget containing abundant inclusions is described here but similar features are observed in other nuggets from the same area. The inclusions contain laurite (RuS2), irarsite–hollingworthite (IrAsS–RhAsS), Pd–Te–Bi–Sb phases, Ir-alloy, Os-alloy, Pd-bearing Au, an Rh–Te phase, Pd–Au alloy and Pd–Pt–Cu alloy. PGM found on the nugget surface include laurite, irarsite and cuprorhodsite (CuRh2S4). The Pd–Te–Bi–Sb phases may include Sb-rich keithconnite (Pd20S7) and compositions close to the kotulskite–sobolevskite solid-solution series (PdTe–BiTe). Textural evidence suggests that formation of the nuggets began with the isoferroplatinum host and the voids were filled starting intergrowths of laurite and irarsite–hollingworthite with both laurite and irarsite–hollingworthite often showing compositional zonation and each of them replacing the other. Filling of the voids probably continued with Pd-Cu-bearing gold, Sb-rich keithconnite (Pd,Pt)20.06(Te,Sb,Bi)6.94, keithconnite, telluropalladinite Pd9(Te,Bi)4, RhTe and finally Ir-alloy and then Os-alloy. The nuggets are thought to be neoform growths in the organic- and bacterial-rich soils of the tropical rain forest cover of the Freetown intrusion. The mineralogical assemblage in the layered gabbros of the intrusion has been previously shown to differ from the alluvial assemblage in the rivers and these inclusions, not seen in Pt3Fe in the unaltered rocks, add a further item to the catalogue of differences.
Heavy mineral concentrates from rivers and river terraces near York, Freetown Peninsula, Sierra Leone have been examined for their platinum-group mineral (PGM) content. The alluvial PGM are 0.1 to 1.5 mm in size and include Cu-bearing isoferroplatinum (Pt3Fe) and disordered Pt3–xFe (x ≤ 0.38), tulameenite (Pt2FeCu), hongshiite (PtCu), cooperite–vysotskite (PtS–PdS), laurite (RuS2), erlichmanite (OsS2), Os-Ir alloy, Os-Ru alloy and native copper.
Are the alluvial nuggets primary or a neoformation? Comparison of the PGM mineralogy of fresh rocks, weathered rocks and the saprolite, with the alluvial suite shows strongly contrasting features highlighted by the mineral assemblage. Cooperite in the fresh rocks is rare in the alluvium whilst Pt-Fe alloys become more abundant. Oxidized PGM are a feature only of the weathering process and disordering of the Pt-Fe alloys develops during weathering. Palladium is much less abundant in the alluvial suite than in the primary minerals whereas Cu, present as Cu-sulfides in the fresh rocks, occurs in the alluvium as a minor component of the Pt-Fe alloys and as hongshiite alteration to the Pt-Fe alloys. The size difference is striking; the primary mineralogy is micrometre-sized whereas the alluvial PGM are three orders of magnitude larger. Delicate PGM with alteration textures are seen only in the weathered rocks whilst delicate dendritic PGM are reported only from the alluvial suite. An organic coating to the alluvial PGM may be indicative of an organic or bacterial involvement. Some alluvial PGM occur in a drainage basin devoid of outcrops of PGE-bearing horizons.
Together these contrasting features of the primary and placer PGM support the proposal that the Freetown nuggets developed as a result of breakdown of the primary PGM during weathering, movement of the PGE in solution, and growth of new PGM in placers with a different mineral assemblage, mineralogy and mineral chemistry.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.