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We compared two Candida auris screening strategies in high-risk patients.
The positivity rates for point prevalence survey (PPS) and admission screening were similar: 3.9% versus 3.4%, respectively, P = 1.00. Approximately 3% of high-risk patients are colonized, thus there is a need for a universal infection prevention approach for C. auris.
A theorem is presented relating the squared multiple correlation of each measure in a battery with the other measures to the unique generalized inverse of the correlation matrix. This theorem is independent of the rank of the correlation matrix and may be utilized for singular correlation matrices. A coefficient is presented which indicates whether the squared multiple correlation is unity or not. Note that not all measures necessarily have unit squared multiple correlations with the other measures when the correlation matrix is singular. Some suggestions for computations are given for simultaneous determination of squared multiple correlations for all measures.
The identification of predictors of treatment response is crucial for improving treatment outcome for children with anxiety disorders. Machine learning methods provide opportunities to identify combinations of factors that contribute to risk prediction models.
Methods
A machine learning approach was applied to predict anxiety disorder remission in a large sample of 2114 anxious youth (5–18 years). Potential predictors included demographic, clinical, parental, and treatment variables with data obtained pre-treatment, post-treatment, and at least one follow-up.
Results
All machine learning models performed similarly for remission outcomes, with AUC between 0.67 and 0.69. There was significant alignment between the factors that contributed to the models predicting two target outcomes: remission of all anxiety disorders and the primary anxiety disorder. Children who were older, had multiple anxiety disorders, comorbid depression, comorbid externalising disorders, received group treatment and therapy delivered by a more experienced therapist, and who had a parent with higher anxiety and depression symptoms, were more likely than other children to still meet criteria for anxiety disorders at the completion of therapy. In both models, the absence of a social anxiety disorder and being treated by a therapist with less experience contributed to the model predicting a higher likelihood of remission.
Conclusions
These findings underscore the utility of prediction models that may indicate which children are more likely to remit or are more at risk of non-remission following CBT for childhood anxiety.
Background: Candida auris infection is associated with high morbidity and mortality. C. auris can persist in the healthcare environment and is associated with outbreaks. We compare screening strategies for C. auris in two high-risk patient populations. Methods: Our center is a tertiary, 865-bed hospital. In the context of known regional outbreaks of C. auris in post-acute care (PAC) facilities, we experienced extended clusters of apparent C. auris acquisition across several hospital units. Hospital acquisition was defined as new C. auris in clinical cultures in patients with no known history of C. auris colonization/infection. We performed point prevalence surveys (PPS) on affected units weekly until all tests were negative for two consecutive weeks. We also initiated admission screening for C. auris for patients admitted from PAC. All screening swabs were collected per CDC’s procedure. Tests were performed either by RT-PCR or Chromagar C. auris media, depending on availability. We compared the overall positivity rates of exposure PPS versus PAC admission screenings using Z-test for two proportions with statistical significance set at p < 0 .05 Results: From 2/2023-12/2023, a total of 533 tests on 367 unique patients were processed during PPS; 512 tests were negative and 21 were positive (3.9% positivity rate). Three additional samples were either unable to be processed or indeterminate. There were 68 patients who had repeat testing weekly for ≥2 weeks. Most remained negative, but 5 tested positive after variable amounts of negative-week intervals: 3 patients at week 2, 1 patient at week 4 and 1 patient at week 5. From 8/2023 to 12/2023, a total of 89 patients admitted from 35 different PAC facilities underwent admission screening for C. auris. Only three patients were positive (3.4%), each from a different facility. The difference in the positivity rates between PPS and PAC was not statistically significant (Z-score 0.25, p = 0.79). Discussion: Our C. auris screening strategies found similar positivity rates for patients admitted to the hospital from PACs compared to targeted PPS in the setting of apparent hospital acquisition events. These strategies may be considered as complementary. Facilities experiencing apparent acquisition events should consider screening high-risk admissions to identify and isolate colonized patients, particularly if standard infection prevention practices are being performed with high fidelity.
Autistic people have a high likelihood of developing mental health difficulties but a low chance of receiving effective mental healthcare. Therefore, there is a need to identify and examine strategies to improve mental healthcare for autistic people.
Aims
To identify strategies that have been implemented to improve access, experiences of care and mental health outcomes for autistic adults, and to examine evidence on their acceptability, feasibility and effectiveness.
Method
A co-produced systematic review was conducted. MEDLINE, PsycINFO, CINHAL, medRxiv and PsyArXiv were searched. We included all study designs reporting acceptability or feasibility outcomes and empirical quantitative study designs reporting effectiveness outcomes. Data were synthesised using a narrative approach.
Results
A total of 30 articles were identified. These included 16 studies of adapted mental health interventions, eight studies of service improvements and six studies of bespoke mental health interventions developed for autistic people. There was no conclusive evidence on effectiveness. However, most bespoke and adapted approaches appeared to be feasible and acceptable. Identified adaptations appeared to be acceptable and feasible, including increasing knowledge and detection of autism, providing environmental adjustments and communication accommodations, accommodating individual differences and modifying the structure and content of interventions.
Conclusion
Many identified strategies are feasible and acceptable, and can be readily implemented in services with the potential to make mental healthcare more suitable for autistic people, but important research gaps remain. Future research should address these and investigate a co-produced package of service improvement measures.
Autistic children and young people (CYP) experience mental health difficulties but face many barriers to accessing and benefiting from mental health care. There is a need to explore strategies in mental health care for autistic CYP to guide clinical practice and future research and support their mental health needs. Our aim was to identify strategies used to improve mental health care for autistic CYP and examine evidence on their acceptability, feasibility, and effectiveness. A systematic review and meta-analysis were carried out. All study designs reporting acceptability/feasibility outcomes and empirical quantitative studies reporting effectiveness outcomes for strategies tested within mental health care were eligible. We conducted a narrative synthesis and separate meta-analyses by informant (self, parent, and clinician). Fifty-seven papers were included, with most investigating cognitive behavioral therapy (CBT)-based interventions for anxiety and several exploring service-level strategies, such as autism screening tools, clinician training, and adaptations regarding organization of services. Most papers described caregiver involvement in therapy and reported adaptations to communication and intervention content; a few reported environmental adjustments. In the meta-analyses, parent- and clinician-reported outcomes, but not self-reported outcomes, showed with moderate certainty that CBT for anxiety was an effective treatment compared to any comparison condition in reducing anxiety symptoms in autistic individuals. The certainty of evidence for effectiveness, synthesized narratively, ranged from low to moderate. Evidence for feasibility and acceptability tended to be positive. Many identified strategies are simple, reasonable adjustments that can be implemented in services to enhance mental health care for autistic individuals. Notable research gaps persist, however.
Offers a unique investigation of the composition of the entire corpus of Beethoven's symphonies, reconstructing their creation through the most extensive study of Beethoven's sketches yet.
Having achieved considerable success with his Akademie (benefit concert) of April 1800, which a reviewer described as ‘probably the most interesting Akademie for a long time’, it was natural that Beethoven should want to repeat his success with a new symphony the following spring, which was almost the only time when theatres in Vienna were available for such concerts. Accordingly he set to work on his Second Symphony towards the end of 1800. In contrast to his First Symphony, numerous sketches survive for the Second, and they have been discussed in considerable detail by Gustav Nottebohm, Kurt Westphal, Cecil Hill and Nicholas Marston, in addition to brief accounts elsewhere. These authors, however, do not provide the full biographical context, which must be obtained from other sources.
The first surviving sketches for the symphony appear in the sketchbook Landsberg 7. This book was begun around September 1800, though no very precise date is available and it could have been a month or two earlier or later. The first part of the book is devoted mainly to two violin sonatas, Opp. 23 and 24, which had apparently been commissioned by Count Moritz Fries, but Beethoven suddenly left off work on them, with Op. 24 far from finished, to work on the new symphony, starting on what is now page 38. Something, perhaps a proposal for a new Akademie the following spring, may therefore have prompted him to make this rapid change of direction. The earliest sketches seem far from tentative, for page 38 includes an extended continuity draft covering virtually the whole of an introduction and ensuing exposition, albeit in a somewhat compressed form of only about fifty-five bars altogether (the final version of this section occupies 133 bars). It must be suspected, therefore, that either some earlier sketches are lost, or that Beethoven worked on the movement at the piano and in his head for some time before writing anything down. Another possibility is that, just as he could improvise a piece fluently without preparation, the draft is a written-down improvisation, where what came into his head was written rather than played on the piano.
There are several striking features in this initial draft.
Although Beethoven’s Ninth Symphony proved to be his last, this was not his intention or expectation when he composed it. As noted in the previous chapter, he had been commissioned in 1817 to write two new symphonies, and while he was drafting the Ninth he noted down occasional ideas about its successor. The first known idea in 1818 was purely verbal and proposed adding voices to the finale of this second symphony, but this plan became absorbed into the Ninth, and it seems hardly probable that he would have wanted to use the idea in both new symphonies. In 1819 he implied to Ferdinand Ries that the two symphonies were at least partially written, saying that he would bring them with him to London the following winter. Then in July 1820, when Franz Xaver Gebauer visited Breslau (now Wrocław), he heard that Beethoven had two new symphonies in progress, and reported this in Beethoven’s conversation book the following month. The earliest known musical sketches for the work, however, are those noted previously that date from about October 1822, appearing near the end of Artaria 201 (pages 124–5) and on a separate bifolio now in Bonn. They show a slow introduction in E flat major leading to a fast section in C minor, plus ideas for three possible later movements. Beethoven considered incorporating both main themes from the first movement into the Ninth Symphony (see Chapter 9), as he had done with the plan for a vocal finale, but he quickly abandoned this idea, leaving them available for future development as the Tenth.
In the theme of the slow introduction the first five notes – even the first seven in some sketches – are identical to the Adagio theme in the Pathétique Sonata, apart from the key (see Example 9.9 above, which shows both versions of the theme at a time when they were being considered for the Ninth Symphony). Beethoven must have noticed this similarity, and may well have had some poetic reason for reusing this theme so conspicuously.
Menuetto: Allegro vivace – Trio: Un poco meno allegro – Tempo I [etc.]
Allegro ma non troppo
Genesis and context
Beethoven had originally planned the Eroica Symphony as one of two that were to be offered to Breitkopf & Härtel. After completing it in autumn 1803, however, he turned to other works: first the opera Vestas Feuer, which he quickly abandoned, and then to piano sonatas, the Triple Concerto and most notably the opera Leonore or Fidelio. These occupied much of the remainder of the sketchbook Landsberg 6, which was finished around the end of March 1804; but at a stage when plans for the opera were held up or in abeyance, he inserted a few new ideas for what was intended to be his next symphony. They are in C minor and eventually emerged in the Fifth (see the next chapter). He also noted down in the sketchbook a few tentative ideas that were later absorbed into the Sixth (Pastoral), but there is no sign of the Fourth here. His next known sketchbook, Mendelssohn 15, contains no confirmed sketches for any symphony. It was probably begun about July 1804, for there is a significant gap in the sketch record for Leonore between the sketches for its earliest numbers (up to No. 5) in Landsberg 6 and sketches for No. 12 onwards in Mendelssohn 15. Although the latter contains sketches for the Triple Concerto, which had been performed on or before 11 June, as noted in the previous chapter, these sketches must postdate the original performance and reflect a very thorough revision that the concerto received thereafter. Such a revision is confirmed by a violin part for the original version, which differs markedly from the one eventually published.
Between Landsberg 6 and Mendelssohn 15 there may be a lost sketchbook containing Nos. 6-11 of Leonore, but Beethoven also used loose leaves, including a batch of ten that has since been split up and resides in four different locations. The batch has been dated to around April–June 1804, since it includes sketches for two Petrarch sonnets in a translation that was not published until 24 May 1804. Late May–July would seem more likely, however, since there are no sketches for the Triple Concerto.
After the concert that included public premieres of Beethoven’s Fifth and Sixth Symphonies in December 1808, it was nearly three years before he embarked on the Seventh. In the meantime, much had changed. He had been offered a permanent position as Kapellmeister at Kassel in late 1808, but this had prompted several noblemen in Vienna to make a counter-proposal early in 1809, consisting of an annuity of 4,000 florins per year, designed to keep him in the capital city. They had surely been impressed by Beethoven’s extraordinary concert of 22 December 1808 in which so many new works, including the two symphonies, had been performed. The contract, drawn up by Baron Ignaz von Gleichenstein, with funds to be provided by Archduke Rudolph, Prince Ferdinand Kinsky and Prince Franz Lobkowitz, recognised Beethoven’s ‘extraordinary talents and genius’ (‘ausserordentlichen Talente und Genie’), and that he should be freed from financial anxiety so as to enable him to produce ‘great, exalted works that ennoble art’ (‘grosse, erhabene, und die Kunst veredelnde Werke’). Beethoven received the contract from Archduke Rudolph on 26 February, and it was signed by the sponsors on 1 March.
The implied expectation was, therefore, that Beethoven would continue composing more symphonies, among other great works, but the next symphony was delayed by various factors; the invasion of Vienna by the French in May 1809 disrupted society so much that Beethoven felt unable to compose anything significant for several months; and inflation reduced the value of his annuity almost immediately. He was also asked to fulfil several commissions – two piano sonatas and a fantasia for Clementi, incidental music to Egmont for the court theatre, fifty-three folksong settings for George Thomson, and in spring to summer 1811 two one-act singspiels, König Stephan and Die Ruinen von Athen, for Pest – plus some works that were probably commissioned, including the Fifth Piano Concerto, two string quartets (Opp. 74 and 95) and the ‘Archduke’ Trio. As soon as he had finished sketching the two singspiels, he began work on his Seventh Symphony, and the final sketches for Die Ruinen von Athen actually appear on the same leaf as some of the first known sketches for the symphony (BNba, BH 105), directly above them.
There is no evidence that anyone else requested, let alone commissioned, a first symphony from Beethoven. The reason he attempted to write one appears to have been purely internal: his sense of obligation to compose, and his desire to master all branches of composition from the simplest to the most advanced, with special concern for the latter. The symphony was, in his mind, the foremost branch of instrumental music, as already noted, and so it was natural that he would gravitate towards it.
Sketches for the actual First Symphony are almost totally lacking – the relevant sketchbook must be lost, but it is worth tracing the long road that Beethoven took in preparation for his first attempt at this pre-eminent instrumental genre. With the models of Haydn and Mozart before him, he was surely hesitant to rush into competing with them, and so his preparations were lengthy and diverse. Orchestral music was mastered through other genres – concertos, orchestral dances, and vocal music with orchestral accompaniment; meanwhile what was regarded as purest symphonic style – short motifs developed intensively, rather than long, lyrical phrases or a parade of different ideas – was explored in other genres such as the piano sonata. At the same time, Beethoven was also sketching themes for possible symphonies, as a third strand in his preparations.
Beethoven’s earliest known idea for a symphony is a draft in C minor and 3/4 metre in piano score (Hess 298 or Unv 1), headed ‘Sinfonia’ and dating from some time between 1786 and 1790 – most probably 1788. It occupies the whole of one side of a page and proceeds almost to the end of the exposition of the first movement. The draft of 111 bars begins on what was originally a verso, and so it may well have continued on the now lost opposite page of a bifolio – perhaps even to the end of the movement on another page. Two variant sketches for short passages appear on the recto (the current verso). The first subject is borrowed direct from the main allegro movement in his Piano Quartet in E flat (WoO 36 No. 1) – originally the second in a group of three piano quartets that are dated 1785 in the autograph score.
Beethoven’s Symphony No. 3 is such a pivotal work, with such a large number of surviving sketches, that it has been the subject of numerous studies, and there are no doubt many more to come. The present account attempts merely to provide an overview of its evolution from conception to publication. There are conflicting accounts of how it originated. According to the ever-inventive Anton Schindler, it was Napoleon’s General Jean Bernadotte (later King Karl XIV of Sweden) who suggested to Beethoven that he compose a work in honour of Napoleon, and Beethoven responded with the Eroica Symphony. Unfortunately the only time when Bernadotte could have met Beethoven was when the general was in Vienna in early 1798, at a time when Beethoven had not written his First Symphony and was clearly not contem-plating his Third. Moreover, at that time Napoleon was not the pre-eminent ruler of France that he had become by the time Beethoven was writing his Second Symphony, and was therefore unlikely to be suggested as the subject for a symphony.
Carl Czerny gives a quite different account. He states that, according to Beethoven’s friend Joseph von Bertolini (1784–1861), ‘the death of the English General Abercrombie gave Beethoven the initial idea of the Eroica Symphony’. Ralph Abercromby (1734–1801), who was Scottish (Czerny used ‘English’ in the sense of English-speaking), died as a result of a wound at the Battle of Alexandria. But this too was well before the Second Symphony had been completed or the Third contemplated, and so Bertolini’s claim seems unlikely, especially as he probably did not know Beethoven at the time. Czerny also claims that the original version of the opening theme was as it appears near the end of the movement, with no dramatic descent to C♯. This claim is not supported by Beethoven’s sketches.
The sketch record is both more prosaic and more dramatic. Beethoven’s Wielhorsky Sketchbook, begun in summer 1802, shows sketches for the Piano Sonata Op. 31 No. 3 followed by some for two sets of piano variations – Op. 34 in F major and Op. 35 on a theme from the finale of his ballet Die Geschöpfe des Prometheus – up to page 43.