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Alcohol milestones and internalizing, externalizing, and executive function: longitudinal and polygenic score associations
- Sarah E. Paul, David A.A. Baranger, Emma C. Johnson, Joshua J. Jackson, Aaron J. Gorelik, Alex P. Miller, Alexander S. Hatoum, Wesley K. Thompson, Michael Strube, Danielle M. Dick, Chella Kamarajan, John R. Kramer, Martin H. Plawecki, Grace Chan, Andrey P. Anokhin, David B. Chorlian, Sivan Kinreich, Jacquelyn L. Meyers, Bernice Porjesz, Howard J. Edenberg, Arpana Agrawal, Kathleen K. Bucholz, Ryan Bogdan
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- Psychological Medicine , First View
- Published online by Cambridge University Press:
- 09 May 2024, pp. 1-14
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Background
Although the link between alcohol involvement and behavioral phenotypes (e.g. impulsivity, negative affect, executive function [EF]) is well-established, the directionality of these associations, specificity to stages of alcohol involvement, and extent of shared genetic liability remain unclear. We estimate longitudinal associations between transitions among alcohol milestones, behavioral phenotypes, and indices of genetic risk.
MethodsData came from the Collaborative Study on the Genetics of Alcoholism (n = 3681; ages 11–36). Alcohol transitions (first: drink, intoxication, alcohol use disorder [AUD] symptom, AUD diagnosis), internalizing, and externalizing phenotypes came from the Semi-Structured Assessment for the Genetics of Alcoholism. EF was measured with the Tower of London and Visual Span Tasks. Polygenic scores (PGS) were computed for alcohol-related and behavioral phenotypes. Cox models estimated associations among PGS, behavior, and alcohol milestones.
ResultsExternalizing phenotypes (e.g. conduct disorder symptoms) were associated with future initiation and drinking problems (hazard ratio (HR)⩾1.16). Internalizing (e.g. social anxiety) was associated with hazards for progression from first drink to severe AUD (HR⩾1.55). Initiation and AUD were associated with increased hazards for later depressive symptoms and suicidal ideation (HR⩾1.38), and initiation was associated with increased hazards for future conduct symptoms (HR = 1.60). EF was not associated with alcohol transitions. Drinks per week PGS was linked with increased hazards for alcohol transitions (HR⩾1.06). Problematic alcohol use PGS increased hazards for suicidal ideation (HR = 1.20).
ConclusionsBehavioral markers of addiction vulnerability precede and follow alcohol transitions, highlighting dynamic, bidirectional relationships between behavior and emerging addiction.
Sex differences in iron status during military training: a prospective cohort study of longitudinal changes and associations with endurance performance and musculoskeletal outcomes
- Thomas J. O’Leary, Sarah Jackson, Rachel M. Izard, Neil P. Walsh, Charlotte V. Coombs, Alexander T. Carswell, Samuel J. Oliver, Jonathan C. Y. Tang, William D. Fraser, Julie P. Greeves
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- Journal:
- British Journal of Nutrition / Volume 131 / Issue 4 / 28 February 2024
- Published online by Cambridge University Press:
- 21 September 2023, pp. 581-592
- Print publication:
- 28 February 2024
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This study investigated sex differences in Fe status, and associations between Fe status and endurance and musculoskeletal outcomes, in military training. In total, 2277 British Army trainees (581 women) participated. Fe markers and endurance performance (2·4 km run) were measured at the start (week 1) and end (week 13) of training. Whole-body areal body mineral density (aBMD) and markers of bone metabolism were measured at week 1. Injuries during training were recorded. Training decreased Hb in men and women (mean change (–0·1 (95 % CI –0·2, –0·0) and –0·7 (95 % CI –0·9, –0·6) g/dl, both P < 0·001) but more so in women (P < 0·001). Ferritin decreased in men and women (–27 (95 % CI –28, –23) and –5 (95 % CI –8, –1) µg/l, both P ≤ 0·001) but more so in men (P < 0·001). Soluble transferrin receptor increased in men and women (2·9 (95 % CI 2·3, 3·6) and 3·8 (95 % CI 2·7, 4·9) nmol/l, both P < 0·001), with no difference between sexes (P = 0·872). Erythrocyte distribution width increased in men (0·3 (95 % CI 0·2, 0·4)%, P < 0·001) but not in women (0·1 (95 % CI –0·1, 0·2)%, P = 0·956). Mean corpuscular volume decreased in men (–1·5 (95 % CI –1·8, –1·1) fL, P < 0·001) but not in women (0·4 (95 % CI –0·4, 1·3) fL, P = 0·087). Lower ferritin was associated with slower 2·4 km run time (P = 0·018), sustaining a lower limb overuse injury (P = 0·048), lower aBMD (P = 0·021) and higher beta C-telopeptide cross-links of type 1 collagen and procollagen type 1 N-terminal propeptide (both P < 0·001) controlling for sex. Improving Fe stores before training may protect Hb in women and improve endurance and protect against injury.
Association of severe mental illness with stroke outcomes and process-of-care quality indicators: nationwide cohort study
- Kelly Fleetwood, Sarah H. Wild, Daniel J. Smith, Stewart W. Mercer, Kirsty Licence, Cathie L. M. Sudlow, Caroline A. Jackson
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- Journal:
- The British Journal of Psychiatry / Volume 221 / Issue 1 / July 2022
- Published online by Cambridge University Press:
- 19 August 2021, pp. 394-401
- Print publication:
- July 2022
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Background
Severe mental illness (SMI) is associated with increased stroke risk, but little is known about how SMI relates to stroke prognosis and receipt of acute care.
AimsTo determine the association between SMI and stroke outcomes and receipt of process-of-care quality indicators (such as timely admission to stroke unit).
MethodWe conducted a cohort study using routinely collected linked data-sets, including adults with a first hospital admission for stroke in Scotland during 1991–2014, with process-of-care quality indicator data available from 2010. We identified pre-existing schizophrenia, bipolar disorder and major depression from hospital records. We used logistic regression to evaluate 30-day, 1-year and 5-year mortality and receipt of process-of-care quality indicators by pre-existing SMI, adjusting for sociodemographic and clinical factors. We used Cox regression to evaluate further stroke and vascular events (stroke and myocardial infarction).
ResultsAmong 228 699 patients who had had a stroke, 1186 (0.5%), 859 (0.4%), 7308 (3.2%) had schizophrenia, bipolar disorder and major depression, respectively. Overall, median follow-up was 2.6 years. Compared with adults without a record of mental illness, 30-day mortality was higher for schizophrenia (adjusted odds ratio (aOR) = 1.33, 95% CI 1.16–1.52), bipolar disorder (aOR = 1.37, 95% CI 1.18–1.60) and major depression (aOR = 1.11, 95% CI 1.05–1.18). Each disorder was also associated with marked increased risk of 1-year and 5-year mortality and further stroke and vascular events. There were no clear differences in receipt of process-of-care quality indicators.
ConclusionsPre-existing SMI was associated with higher risks of mortality and further vascular events. Urgent action is needed to better understand and address the reasons for these disparities.
Deactivation of SARS-CoV-2 with pulsed-xenon ultraviolet light: Implications for environmental COVID-19 control
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- Sarah E. Simmons, Ricardo Carrion, Jr, Kendra J. Alfson, Hilary M. Staples, Chetan Jinadatha, William R. Jarvis, Priya Sampathkumar, Roy F. Chemaly, Fareed Khawaja, Mark Povroznik, Stephanie Jackson, Keith S. Kaye, Robert M. Rodriguez, Mark A. Stibich
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 42 / Issue 2 / February 2021
- Published online by Cambridge University Press:
- 03 August 2020, pp. 127-130
- Print publication:
- February 2021
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Objectives:
Prolonged survival of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on environmental surfaces and personal protective equipment may lead to these surfaces transmitting this pathogen to others. We sought to determine the effectiveness of a pulsed-xenon ultraviolet (PX-UV) disinfection system in reducing the load of SARS-CoV-2 on hard surfaces and N95 respirators.
Methods:Chamber slides and N95 respirator material were directly inoculated with SARS-CoV-2 and were exposed to different durations of PX-UV.
Results:For hard surfaces, disinfection for 1, 2, and 5 minutes resulted in 3.53 log10, >4.54 log10, and >4.12 log10 reductions in viral load, respectively. For N95 respirators, disinfection for 5 minutes resulted in >4.79 log10 reduction in viral load. PX-UV significantly reduced SARS-CoV-2 on hard surfaces and N95 respirators.
Conclusion:With the potential to rapidly disinfectant environmental surfaces and N95 respirators, PX-UV devices are a promising technology to reduce environmental and personal protective equipment bioburden and to enhance both healthcare worker and patient safety by reducing the risk of exposure to SARS-CoV-2.
The GLEAM 4-Jy (G4Jy) Sample: I. Definition and the catalogue
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- Sarah V. White, Thomas M. O Franzen, Chris J. Riseley, O. Ivy Wong, Anna D. Kapińska, Natasha Hurley-Walker, Joseph R. Callingham, Kshitij Thorat, Chen Wu, Paul Hancock, Richard W. Hunstead, Nick Seymour, Jesse Swan, Randall Wayth, John Morgan, Rajan Chhetri, Carole Jackson, Stuart Weston, Martin Bell, Bi-Qing For, B. M. Gaensler, Melanie Johnston-Hollitt, André Offringa, Lister Staveley-Smith
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- Journal:
- Publications of the Astronomical Society of Australia / Volume 37 / 2020
- Published online by Cambridge University Press:
- 01 June 2020, e018
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The Murchison Widefield Array (MWA) has observed the entire southern sky (Declination,
$\delta< 30^{\circ}$ ) at low radio frequencies, over the range 72–231MHz. These observations constitute the GaLactic and Extragalactic All-sky MWA (GLEAM) Survey, and we use the extragalactic catalogue (EGC) (Galactic latitude,
$|b| >10^{\circ}$ ) to define the GLEAM 4-Jy (G4Jy) Sample. This is a complete sample of the ‘brightest’ radio sources (
$S_{\textrm{151\,MHz}}>4\,\text{Jy}$ ), the majority of which are active galactic nuclei with powerful radio jets. Crucially, low-frequency observations allow the selection of such sources in an orientation-independent way (i.e. minimising the bias caused by Doppler boosting, inherent in high-frequency surveys). We then use higher-resolution radio images, and information at other wavelengths, to morphologically classify the brightest components in GLEAM. We also conduct cross-checks against the literature and perform internal matching, in order to improve sample completeness (which is estimated to be
$>95.5$ %). This results in a catalogue of 1863 sources, making the G4Jy Sample over 10 times larger than that of the revised Third Cambridge Catalogue of Radio Sources (3CRR;
$S_{\textrm{178\,MHz}}>10.9\,\text{Jy}$ ). Of these G4Jy sources, 78 are resolved by the MWA (Phase-I) synthesised beam (
$\sim2$ arcmin at 200MHz), and we label 67% of the sample as ‘single’, 26% as ‘double’, 4% as ‘triple’, and 3% as having ‘complex’ morphology at
$\sim1\,\text{GHz}$ (45 arcsec resolution). We characterise the spectral behaviour of these objects in the radio and find that the median spectral index is
$\alpha=-0.740 \pm 0.012$ between 151 and 843MHz, and
$\alpha=-0.786 \pm 0.006$ between 151MHz and 1400MHz (assuming a power-law description,
$S_{\nu} \propto \nu^{\alpha}$ ), compared to
$\alpha=-0.829 \pm 0.006$ within the GLEAM band. Alongside this, our value-added catalogue provides mid-infrared source associations (subject to 6” resolution at 3.4
$\mu$ m) for the radio emission, as identified through visual inspection and thorough checks against the literature. As such, the G4Jy Sample can be used as a reliable training set for cross-identification via machine-learning algorithms. We also estimate the angular size of the sources, based on their associated components at
$\sim1\,\text{GHz}$ , and perform a flux density comparison for 67 G4Jy sources that overlap with 3CRR. Analysis of multi-wavelength data, and spectral curvature between 72MHz and 20GHz, will be presented in subsequent papers, and details for accessing all G4Jy overlays are provided at https://github.com/svw26/G4Jy.
The GLEAM 4-Jy (G4Jy) Sample: II. Host galaxy identification for individual sources
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- Sarah V. White, Thomas M. O. Franzen, Chris J. Riseley, O. Ivy Wong, Anna D. Kapińska, Natasha Hurley-Walker, Joseph R. Callingham, Kshitij Thorat, Chen Wu, Paul Hancock, Richard W. Hunstead, Nick Seymour, Jesse Swan, Randall Wayth, John Morgan, Rajan Chhetri, Carole Jackson, Stuart Weston, Martin Bell, B. M. Gaensler, Melanie Johnston–Hollitt, André Offringa, Lister Staveley–Smith
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- Journal:
- Publications of the Astronomical Society of Australia / Volume 37 / 2020
- Published online by Cambridge University Press:
- 01 June 2020, e017
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The entire southern sky (Declination,
$\delta< 30^{\circ}$ ) has been observed using the Murchison Widefield Array (MWA), which provides radio imaging of
$\sim$ 2 arcmin resolution at low frequencies (72–231 MHz). This is the GaLactic and Extragalactic All-sky MWA (GLEAM) Survey, and we have previously used a combination of visual inspection, cross-checks against the literature, and internal matching to identify the ‘brightest’ radio-sources (
$S_{\mathrm{151\,MHz}}>4$ Jy) in the extragalactic catalogue (Galactic latitude,
$|b| >10^{\circ}$ ). We refer to these 1 863 sources as the GLEAM 4-Jy (G4Jy) Sample, and use radio images (of
${\leq}45$ arcsec resolution), and multi-wavelength information, to assess their morphology and identify the galaxy that is hosting the radio emission (where appropriate). Details of how to access all of the overlays used for this work are available at https://github.com/svw26/G4Jy. Alongside this we conduct further checks against the literature, which we document here for individual sources. Whilst the vast majority of the G4Jy Sample are active galactic nuclei with powerful radio-jets, we highlight that it also contains a nebula, two nearby, star-forming galaxies, a cluster relic, and a cluster halo. There are also three extended sources for which we are unable to infer the mechanism that gives rise to the low-frequency emission. In the G4Jy catalogue we provide mid-infrared identifications for 86% of the sources, and flag the remainder as: having an uncertain identification (129 sources), having a faint/uncharacterised mid-infrared host (126 sources), or it being inappropriate to specify a host (2 sources). For the subset of 129 sources, there is ambiguity concerning candidate host-galaxies, and this includes four sources (B0424–728, B0703–451, 3C 198, and 3C 403.1) where we question the existing identification.
Incidence of ischaemic heart disease and stroke among people with psychiatric disorders: retrospective cohort study
- Caroline A. Jackson, Joannes Kerssens, Kelly Fleetwood, Daniel J. Smith, Stewart W. Mercer, Sarah H. Wild
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- Journal:
- The British Journal of Psychiatry / Volume 217 / Issue 2 / August 2020
- Published online by Cambridge University Press:
- 22 November 2019, pp. 442-449
- Print publication:
- August 2020
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Background
Psychiatric disorders are associated with increased risk of ischaemic heart disease (IHD) and stroke, but it is not known whether the associations or the role of sociodemographic factors have changed over time.
AimsTo investigate the association between psychiatric disorders and IHD and stroke, by time period and sociodemographic factors.
MethodWe used Scottish population-based records from 1991 to 2015 to create retrospective cohorts with a hospital record for psychiatric disorders of interest (schizophrenia, bipolar disorder or depression) or no record of hospital admission for mental illness. We estimated incidence and relative risks of IHD and stroke in people with versus without psychiatric disorders by calendar year, age, gender and area-based deprivation level.
ResultsIn all cohorts, incidence of IHD (645 393 events) and stroke (276 073 events) decreased over time, but relative risks decreased for depression only. In 2015, at the mean age at event onset, relative risks were 2- to 2.5-fold higher in people with versus without a psychiatric disorder. Age at incidence of outcome differed by cohort, gender and socioeconomic status. Relative but not absolute risks were generally higher in women than men. Increasing deprivation conveys a greater absolute risk of IHD for people with bipolar disorder or depression.
ConclusionsDespite declines in absolute rates of IHD and stroke, relative risks remain high in those with versus without psychiatric disorders. Cardiovascular disease monitoring and prevention approaches may need to be tailored by psychiatric disorder and cardiovascular outcome, and be targeted, for example, by age and deprivation level.
Patient contact is the main risk factor for vancomycin-resistant Enterococcus contamination of healthcare workers’ gloves and gowns in the intensive care unit
- Sarah S. Jackson, Kerri A. Thom, Laurence S. Magder, Kristen A. Stafford, J. Kristie Johnson, Loren G. Miller, David P. Calfee, Anthony D. Harris, for the CDC Prevention Epicenters Program
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 39 / Issue 9 / September 2018
- Published online by Cambridge University Press:
- 27 July 2018, pp. 1063-1067
- Print publication:
- September 2018
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Objective
To determine which healthcare worker (HCW) roles and patient care activities are associated with acquisition of vancomycin-resistant Enterococcus (VRE) on HCW gloves or gowns after patient care, as a surrogate for transmission to other patients.
DesignProspective cohort study.
SettingMedical and surgical intensive care units at a tertiary-care academic institution.
ParticipantsVRE-colonized patients on Contact Precautions and their HCWs.
MethodsOverall, 94 VRE-colonized patients and 469 HCW–patient interactions were observed. Research staff recorded patient care activities and cultured HCW gloves and gowns for VRE before doffing and exiting patient room.
ResultsVRE were isolated from 71 of 469 HCWs’ gloves or gowns (15%) following patient care. Occupational/physical therapists, patient care technicians, nurses, and physicians were more likely than environmental services workers and other HCWs to have contaminated gloves or gowns. Compared to touching the environment alone, the odds ratio (OR) for VRE contamination associated with touching both the patient (or objects in the immediate vicinity of the patient) and environment was 2.78 (95% confidence interval [CI], 0.99–0.77) and the OR associated with touching only the patient (or objects in the immediate vicinity) was 3.65 (95% CI, 1.17–11.41). Independent risk factors for transmission of VRE to HCWs were touching the patient’s skin (OR, 2.18; 95% CI, 1.15–4.13) and transferring the patient into or out of bed (OR, 2.66; 95% CI, 1.15–6.43).
ConclusionPatient contact is a major risk factor for HCW contamination and subsequent transmission. Interventions should prioritize contact precautions and hand hygiene for HCWs whose activities involve touching the patient.
Electronically Available Comorbid Conditions for Risk Prediction of Healthcare-Associated Clostridium difficile Infection
- Anthony D. Harris, Alyssa N. Sbarra, Surbhi Leekha, Sarah S. Jackson, J. Kristie Johnson, Lisa Pineles, Kerri A. Thom
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 39 / Issue 3 / March 2018
- Published online by Cambridge University Press:
- 05 February 2018, pp. 297-301
- Print publication:
- March 2018
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OBJECTIVE
To analyze whether electronically available comorbid conditions are risk factors for Centers for Disease Control and Prevention (CDC)-defined, hospital-onset Clostridium difficile infection (CDI) after controlling for antibiotic and gastric acid suppression therapy use.
PATIENTSPatients aged ≥18 years admitted to the University of Maryland Medical Center between November 7, 2015, and May 31, 2017.
METHODSComorbid conditions were assessed using the Elixhauser comorbidity index. The Elixhauser comorbidity index and the comorbid condition components were calculated using the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes extracted from electronic medical records. Bivariate associations between CDI and potential covariates for multivariable regression, including antibiotic use, gastric acid suppression therapy use, as well as comorbid conditions, were estimated using log binomial multivariable regression.
RESULTSAfter controlling for antibiotic use, age, proton-pump inhibitor use, and histamine-blocker use, the Elixhauser comorbidity index was a significant risk factor for predicting CDI. There was an increased risk of 1.26 (95% CI, 1.19–1.32) of having CDI for each additional Elixhauser point added to the total Elixhauser score.
CONCLUSIONSAn increase in Elixhauser score is associated with CDI. Our study and other studies have shown that comorbid conditions are important risk factors for CDI. Electronically available comorbid conditions and scores like the Elixhauser index should be considered for risk-adjustment of CDC CDI rates.
Infect Control Hosp Epidemiol 2018;39:297–301
Guidance on Frequency and Location of Environmental Sampling for Acinetobacter baumannii
- Alyssa N. Sbarra, Anthony D. Harris, J. Kristie Johnson, Laurence S. Madger, Lyndsay M. O’Hara, Sarah S. Jackson, Kerri A. Thom
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 39 / Issue 3 / March 2018
- Published online by Cambridge University Press:
- 30 January 2018, pp. 339-342
- Print publication:
- March 2018
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We assessed various locations and frequency of environmental sampling to maximize information and maintain efficiency when sampling for Acinetobacter baumannii. Although sampling sites in closer proximity to the patient were more likely positive, to fully capture environmental contamination, we found value in sampling all sites and across multiple days.
Infect Control Hosp Epidemiol 2018;39:339–342
The Effect of Adding Comorbidities to Current Centers for Disease Control and Prevention Central-Line–Associated Bloodstream Infection Risk-Adjustment Methodology
- Sarah S. Jackson, Surbhi Leekha, Laurence S. Magder, Lisa Pineles, Deverick J. Anderson, William E. Trick, Keith F. Woeltje, Keith S. Kaye, Kristen Stafford, Kerri Thom, Timothy J. Lowe, Anthony D. Harris
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 38 / Issue 9 / September 2017
- Published online by Cambridge University Press:
- 03 July 2017, pp. 1019-1024
- Print publication:
- September 2017
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BACKGROUND
Risk adjustment is needed to fairly compare central-line–associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes.
METHODSUsing a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank.
RESULTSOverall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51–0.59) for the ICU-type model and 0.64 (95% CI, 0.60–0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model.
CONCLUSIONSOur risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals.
Infect Control Hosp Epidemiol 2017;38:1019–1024
Pseudomonas aeruginosa Colonization in the Intensive Care Unit: Prevalence, Risk Factors, and Clinical Outcomes
- Anthony D. Harris, Sarah S. Jackson, Gwen Robinson, Lisa Pineles, Surbhi Leekha, Kerri A. Thom, Yuan Wang, Michelle Doll, Melinda M. Pettigrew, J. Kristie Johnson
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 37 / Issue 5 / May 2016
- Published online by Cambridge University Press:
- 01 February 2016, pp. 544-548
- Print publication:
- May 2016
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OBJECTIVE
To determine the prevalence of Pseudomonas aeruginosa colonization on intensive care unit (ICU) admission, risk factors for P. aeruginosa colonization, and the incidence of subsequent clinical culture with P. aeruginosa among those colonized and not colonized.
METHODSWe conducted a cohort study of patients admitted to a medical or surgical intensive care unit of a tertiary care hospital. Patients had admission perirectal surveillance cultures performed. Risk factors analyzed included comorbidities at admission, age, sex, antibiotics received during current hospitalization before ICU admission, and type of ICU.
RESULTSOf 1,840 patients, 213 (11.6%) were colonized with P. aeruginosa on ICU admission. Significant risk factors in the multivariable analysis for colonization were age (odds ratio, 1.02 [95% CI, 1.01–1.03]), anemia (1.90 [1.05–3.42]), and neurologic disorder (1.80 [1.27–2.54]). Of the 213 patients colonized with P. aeruginosa on admission, 41 (19.2%) had a subsequent clinical culture positive for P. aeruginosa on ICU admission and 60 (28.2%) had a subsequent clinical culture positive for P. aeruginosa in the current hospitalization (ICU period and post-ICU period). Of these 60 patients, 49 (81.7%) had clinical infections. Of the 1,627 patients not colonized on admission, only 68 (4.2%) had a subsequent clinical culture positive for P. aeruginosa in the current hospitalization. Patients colonized with P. aeruginosa were more likely to have a subsequent positive clinical culture than patients not colonized (incidence rate ratio, 6.74 [95% CI, 4.91–9.25]).
CONCLUSIONSPrediction rules or rapid diagnostic testing will help clinicians more appropriately choose empirical antibiotic therapy for subsequent infections.
Infect Control Hosp Epidemiol 2016;37:544–548
Contributors
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- By Mitchell Aboulafia, Frederick Adams, Marilyn McCord Adams, Robert M. Adams, Laird Addis, James W. Allard, David Allison, William P. Alston, Karl Ameriks, C. Anthony Anderson, David Leech Anderson, Lanier Anderson, Roger Ariew, David Armstrong, Denis G. Arnold, E. J. Ashworth, Margaret Atherton, Robin Attfield, Bruce Aune, Edward Wilson Averill, Jody Azzouni, Kent Bach, Andrew Bailey, Lynne Rudder Baker, Thomas R. Baldwin, Jon Barwise, George Bealer, William Bechtel, Lawrence C. Becker, Mark A. Bedau, Ernst Behler, José A. Benardete, Ermanno Bencivenga, Jan Berg, Michael Bergmann, Robert L. Bernasconi, Sven Bernecker, Bernard Berofsky, Rod Bertolet, Charles J. Beyer, Christian Beyer, Joseph Bien, Joseph Bien, Peg Birmingham, Ivan Boh, James Bohman, Daniel Bonevac, Laurence BonJour, William J. Bouwsma, Raymond D. Bradley, Myles Brand, Richard B. Brandt, Michael E. Bratman, Stephen E. Braude, Daniel Breazeale, Angela Breitenbach, Jason Bridges, David O. Brink, Gordon G. Brittan, Justin Broackes, Dan W. Brock, Aaron Bronfman, Jeffrey E. Brower, Bartosz Brozek, Anthony Brueckner, Jeffrey Bub, Lara Buchak, Otavio Bueno, Ann E. Bumpus, Robert W. Burch, John Burgess, Arthur W. Burks, Panayot Butchvarov, Robert E. Butts, Marina Bykova, Patrick Byrne, David Carr, Noël Carroll, Edward S. Casey, Victor Caston, Victor Caston, Albert Casullo, Robert L. Causey, Alan K. L. Chan, Ruth Chang, Deen K. Chatterjee, Andrew Chignell, Roderick M. Chisholm, Kelly J. Clark, E. J. Coffman, Robin Collins, Brian P. Copenhaver, John Corcoran, John Cottingham, Roger Crisp, Frederick J. Crosson, Antonio S. Cua, Phillip D. Cummins, Martin Curd, Adam Cureton, Andrew Cutrofello, Stephen Darwall, Paul Sheldon Davies, Wayne A. Davis, Timothy Joseph Day, Claudio de Almeida, Mario De Caro, Mario De Caro, John Deigh, C. F. Delaney, Daniel C. Dennett, Michael R. DePaul, Michael Detlefsen, Daniel Trent Devereux, Philip E. Devine, John M. Dillon, Martin C. Dillon, Robert DiSalle, Mary Domski, Alan Donagan, Paul Draper, Fred Dretske, Mircea Dumitru, Wilhelm Dupré, Gerald Dworkin, John Earman, Ellery Eells, Catherine Z. Elgin, Berent Enç, Ronald P. Endicott, Edward Erwin, John Etchemendy, C. Stephen Evans, Susan L. Feagin, Solomon Feferman, Richard Feldman, Arthur Fine, Maurice A. Finocchiaro, William FitzPatrick, Richard E. Flathman, Gvozden Flego, Richard Foley, Graeme Forbes, Rainer Forst, Malcolm R. Forster, Daniel Fouke, Patrick Francken, Samuel Freeman, Elizabeth Fricker, Miranda Fricker, Michael Friedman, Michael Fuerstein, Richard A. Fumerton, Alan Gabbey, Pieranna Garavaso, Daniel Garber, Jorge L. A. Garcia, Robert K. Garcia, Don Garrett, Philip Gasper, Gerald Gaus, Berys Gaut, Bernard Gert, Roger F. Gibson, Cody Gilmore, Carl Ginet, Alan H. Goldman, Alvin I. Goldman, Alfonso Gömez-Lobo, Lenn E. Goodman, Robert M. Gordon, Stefan Gosepath, Jorge J. E. Gracia, Daniel W. Graham, George A. Graham, Peter J. Graham, Richard E. Grandy, I. Grattan-Guinness, John Greco, Philip T. Grier, Nicholas Griffin, Nicholas Griffin, David A. Griffiths, Paul J. Griffiths, Stephen R. Grimm, Charles L. Griswold, Charles B. Guignon, Pete A. Y. Gunter, Dimitri Gutas, Gary Gutting, Paul Guyer, Kwame Gyekye, Oscar A. Haac, Raul Hakli, Raul Hakli, Michael Hallett, Edward C. Halper, Jean Hampton, R. James Hankinson, K. R. Hanley, Russell Hardin, Robert M. Harnish, William Harper, David Harrah, Kevin Hart, Ali Hasan, William Hasker, John Haugeland, Roger Hausheer, William Heald, Peter Heath, Richard Heck, John F. Heil, Vincent F. Hendricks, Stephen Hetherington, Francis Heylighen, Kathleen Marie Higgins, Risto Hilpinen, Harold T. Hodes, Joshua Hoffman, Alan Holland, Robert L. Holmes, Richard Holton, Brad W. Hooker, Terence E. Horgan, Tamara Horowitz, Paul Horwich, Vittorio Hösle, Paul Hoβfeld, Daniel Howard-Snyder, Frances Howard-Snyder, Anne Hudson, Deal W. Hudson, Carl A. Huffman, David L. Hull, Patricia Huntington, Thomas Hurka, Paul Hurley, Rosalind Hursthouse, Guillermo Hurtado, Ronald E. Hustwit, Sarah Hutton, Jonathan Jenkins Ichikawa, Harry A. Ide, David Ingram, Philip J. Ivanhoe, Alfred L. Ivry, Frank Jackson, Dale Jacquette, Joseph Jedwab, Richard Jeffrey, David Alan Johnson, Edward Johnson, Mark D. Jordan, Richard Joyce, Hwa Yol Jung, Robert Hillary Kane, Tomis Kapitan, Jacquelyn Ann K. Kegley, James A. Keller, Ralph Kennedy, Sergei Khoruzhii, Jaegwon Kim, Yersu Kim, Nathan L. King, Patricia Kitcher, Peter D. Klein, E. D. Klemke, Virginia Klenk, George L. Kline, Christian Klotz, Simo Knuuttila, Joseph J. Kockelmans, Konstantin Kolenda, Sebastian Tomasz Kołodziejczyk, Isaac Kramnick, Richard Kraut, Fred Kroon, Manfred Kuehn, Steven T. Kuhn, Henry E. Kyburg, John Lachs, Jennifer Lackey, Stephen E. Lahey, Andrea Lavazza, Thomas H. Leahey, Joo Heung Lee, Keith Lehrer, Dorothy Leland, Noah M. Lemos, Ernest LePore, Sarah-Jane Leslie, Isaac Levi, Andrew Levine, Alan E. Lewis, Daniel E. Little, Shu-hsien Liu, Shu-hsien Liu, Alan K. L. Chan, Brian Loar, Lawrence B. Lombard, John Longeway, Dominic McIver Lopes, Michael J. Loux, E. J. Lowe, Steven Luper, Eugene C. Luschei, William G. Lycan, David Lyons, David Macarthur, Danielle Macbeth, Scott MacDonald, Jacob L. Mackey, Louis H. Mackey, Penelope Mackie, Edward H. Madden, Penelope Maddy, G. B. Madison, Bernd Magnus, Pekka Mäkelä, Rudolf A. Makkreel, David Manley, William E. Mann (W.E.M.), Vladimir Marchenkov, Peter Markie, Jean-Pierre Marquis, Ausonio Marras, Mike W. Martin, A. P. Martinich, William L. McBride, David McCabe, Storrs McCall, Hugh J. McCann, Robert N. McCauley, John J. McDermott, Sarah McGrath, Ralph McInerny, Daniel J. McKaughan, Thomas McKay, Michael McKinsey, Brian P. McLaughlin, Ernan McMullin, Anthonie Meijers, Jack W. Meiland, William Jason Melanson, Alfred R. Mele, Joseph R. Mendola, Christopher Menzel, Michael J. Meyer, Christian B. Miller, David W. Miller, Peter Millican, Robert N. Minor, Phillip Mitsis, James A. Montmarquet, Michael S. Moore, Tim Moore, Benjamin Morison, Donald R. Morrison, Stephen J. Morse, Paul K. Moser, Alexander P. D. Mourelatos, Ian Mueller, James Bernard Murphy, Mark C. Murphy, Steven Nadler, Jan Narveson, Alan Nelson, Jerome Neu, Samuel Newlands, Kai Nielsen, Ilkka Niiniluoto, Carlos G. Noreña, Calvin G. Normore, David Fate Norton, Nikolaj Nottelmann, Donald Nute, David S. Oderberg, Steve Odin, Michael O’Rourke, Willard G. Oxtoby, Heinz Paetzold, George S. Pappas, Anthony J. Parel, Lydia Patton, R. P. Peerenboom, Francis Jeffry Pelletier, Adriaan T. Peperzak, Derk Pereboom, Jaroslav Peregrin, Glen Pettigrove, Philip Pettit, Edmund L. Pincoffs, Andrew Pinsent, Robert B. Pippin, Alvin Plantinga, Louis P. Pojman, Richard H. Popkin, John F. Post, Carl J. Posy, William J. Prior, Richard Purtill, Michael Quante, Philip L. Quinn, Philip L. Quinn, Elizabeth S. Radcliffe, Diana Raffman, Gerard Raulet, Stephen L. Read, Andrews Reath, Andrew Reisner, Nicholas Rescher, Henry S. Richardson, Robert C. Richardson, Thomas Ricketts, Wayne D. Riggs, Mark Roberts, Robert C. Roberts, Luke Robinson, Alexander Rosenberg, Gary Rosenkranz, Bernice Glatzer Rosenthal, Adina L. Roskies, William L. Rowe, T. M. Rudavsky, Michael Ruse, Bruce Russell, Lilly-Marlene Russow, Dan Ryder, R. M. Sainsbury, Joseph Salerno, Nathan Salmon, Wesley C. Salmon, Constantine Sandis, David H. Sanford, Marco Santambrogio, David Sapire, Ruth A. Saunders, Geoffrey Sayre-McCord, Charles Sayward, James P. Scanlan, Richard Schacht, Tamar Schapiro, Frederick F. Schmitt, Jerome B. Schneewind, Calvin O. Schrag, Alan D. Schrift, George F. Schumm, Jean-Loup Seban, David N. Sedley, Kenneth Seeskin, Krister Segerberg, Charlene Haddock Seigfried, Dennis M. Senchuk, James F. Sennett, William Lad Sessions, Stewart Shapiro, Tommie Shelby, Donald W. Sherburne, Christopher Shields, Roger A. Shiner, Sydney Shoemaker, Robert K. Shope, Kwong-loi Shun, Wilfried Sieg, A. John Simmons, Robert L. Simon, Marcus G. Singer, Georgette Sinkler, Walter Sinnott-Armstrong, Matti T. Sintonen, Lawrence Sklar, Brian Skyrms, Robert C. Sleigh, Michael Anthony Slote, Hans Sluga, Barry Smith, Michael Smith, Robin Smith, Robert Sokolowski, Robert C. Solomon, Marta Soniewicka, Philip Soper, Ernest Sosa, Nicholas Southwood, Paul Vincent Spade, T. L. S. Sprigge, Eric O. Springsted, George J. Stack, Rebecca Stangl, Jason Stanley, Florian Steinberger, Sören Stenlund, Christopher Stephens, James P. Sterba, Josef Stern, Matthias Steup, M. A. Stewart, Leopold Stubenberg, Edith Dudley Sulla, Frederick Suppe, Jere Paul Surber, David George Sussman, Sigrún Svavarsdóttir, Zeno G. Swijtink, Richard Swinburne, Charles C. Taliaferro, Robert B. Talisse, John Tasioulas, Paul Teller, Larry S. Temkin, Mark Textor, H. S. Thayer, Peter Thielke, Alan Thomas, Amie L. Thomasson, Katherine Thomson-Jones, Joshua C. Thurow, Vzalerie Tiberius, Terrence N. Tice, Paul Tidman, Mark C. Timmons, William Tolhurst, James E. Tomberlin, Rosemarie Tong, Lawrence Torcello, Kelly Trogdon, J. D. Trout, Robert E. Tully, Raimo Tuomela, John Turri, Martin M. Tweedale, Thomas Uebel, Jennifer Uleman, James Van Cleve, Harry van der Linden, Peter van Inwagen, Bryan W. Van Norden, René van Woudenberg, Donald Phillip Verene, Samantha Vice, Thomas Vinci, Donald Wayne Viney, Barbara Von Eckardt, Peter B. M. Vranas, Steven J. Wagner, William J. Wainwright, Paul E. Walker, Robert E. Wall, Craig Walton, Douglas Walton, Eric Watkins, Richard A. Watson, Michael V. Wedin, Rudolph H. Weingartner, Paul Weirich, Paul J. Weithman, Carl Wellman, Howard Wettstein, Samuel C. Wheeler, Stephen A. White, Jennifer Whiting, Edward R. Wierenga, Michael Williams, Fred Wilson, W. Kent Wilson, Kenneth P. Winkler, John F. Wippel, Jan Woleński, Allan B. Wolter, Nicholas P. Wolterstorff, Rega Wood, W. Jay Wood, Paul Woodruff, Alison Wylie, Gideon Yaffe, Takashi Yagisawa, Yutaka Yamamoto, Keith E. Yandell, Xiaomei Yang, Dean Zimmerman, Günter Zoller, Catherine Zuckert, Michael Zuckert, Jack A. Zupko (J.A.Z.)
- Edited by Robert Audi, University of Notre Dame, Indiana
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- The Cambridge Dictionary of Philosophy
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- 05 August 2015
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- 27 April 2015, pp ix-xxx
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Therapy Contamination as a Measure of Therapist Treatment Adherence in a Trial of Cognitive Behaviour Therapy versus Befriending for Psychosis
- Sarah Bendall, Kelly Allott, Martina Jovev, Marie-Josee Marois, Eoin J. Killackey, John F. Gleeson, Mario Alvarez-Jimenez, Patrick D. McGorry, Henry J. Jackson
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- Behavioural and Cognitive Psychotherapy / Volume 43 / Issue 3 / May 2015
- Published online by Cambridge University Press:
- 29 October 2013, pp. 314-327
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- May 2015
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Background: High quality randomized controlled trials (RCT) of psychotherapeutic interventions should ensure that the therapy being tested is what is actually delivered. However, contamination of one therapy into the other, a critical component of treatment adherence, is seldom measured in psychotherapy trials of psychosis. Aims: The aim of the study was to determine whether a purpose-designed measure, the ACE Treatment Integrity Measure (ATIM) could detect therapy contaminations within a controlled trial of cognitive behavioural therapy (CBT) versus Befriending for first-episode psychosis and to compare the ATIM to a more traditional adherence measure, the Cognitive Therapy Scale (CTS). Method: Therapy sessions were audio-recorded and at least one therapy session from 53 of the 62 participants in the RCT was rated by an independent rater using the CTS and ATIM. Results: Ninety-nine therapy sessions were rated. All Befriending sessions and all but three CBT sessions were correctly identified. The ATIM showed that 29 of the 99 (29%) sessions were contaminated by techniques from the other therapy. Within the CBT sessions, 19 of the 51 sessions (37%) were contaminated by one or more Befriending techniques. Of the Befriending sessions, 10 of 48 (21%) were contaminated by ACE techniques. The mean CTS score was higher in the CBT than the Befriending group. Conclusions: The ATIM was able to detect contaminations and revealed more meaningful, fine-grained analysis of what therapy techniques were being delivered and what contaminations occurred. The study highlights the benefit of employing purpose-designed measures that include contamination when assessing treatment adherence.
Contributors
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- By Kumar Alagappan, Janet G. Alteveer, Kim Askew, Paul S. Auerbach, Katherine Bakes, Kip Benko, Paul D. Biddinger, Victoria Brazil, Anthony FT Brown, Andrew K. Chang, Alice Chiao, Wendy C. Coates, Jamie Collings, Gilbert Abou Dagher, Jonathan E. Davis, Peter DeBlieux, Alessandro Dellai, Emily Doelger, Pamela L. Dyne, Gino Farina, Robert Galli, Gus M. Garmel, Daniel Garza, Laleh Gharahbaghian, Gregory H. Gilbert, Michael A. Gisondi, Steven Go, Jeffrey M. Goodloe, Swaminatha V. Gurudevan, Micelle J. Haydel, Stephen R. Hayden, Corey R. Heitz, Gregory W. Hendey, Mel Herbert, Cherri Hobgood, Michelle Huston, Loretta Jackson-Williams, Anja K. Jaehne, Mary Beth Johnson, H. Brendan Kelleher, Peter G Kumasaka, Melissa J. Lamberson, Mary Lanctot-Herbert, Erik Laurin, Brian Lin, Michelle Lin, Douglas Lowery-North, Sharon E. Mace, S. V. Mahadevan, Thomas M. Mailhot, Diku Mandavia, David E. Manthey, Jorge A. Martinez, Amal Mattu, Lynne McCullough, Steve McLaughlin, Timothy Meyers, Gregory J. Moran, Randall T. Myers, Christopher R.H. Newton, Flavia Nobay, Robert L. Norris, Catherine Oliver, Jennifer A. Oman, Rita Oregon, Phillips Perera, Susan B. Promes, Emanuel P. Rivers, John S. Rose, Carolyn J. Sachs, Jairo I. Santanilla, Rawle A. Seupaul, Fred A. Severyn, Ghazala Q. Sharieff, Lee W. Shockley, Stefanie Simmons, Barry C. Simon, Shannon Sovndal, George Sternbach, Matthew Strehlow, Eustacia (Jo) Su, Stuart P. Swadron, Jeffrey A. Tabas, Sophie Terp, R. Jason Thurman, David A. Wald, Sarah R. Williams, Teresa S. Wu, Ken Zafren
- Edited by S. V. Mahadevan, Stanford University School of Medicine, California, Gus M. Garmel
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- An Introduction to Clinical Emergency Medicine
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- 05 May 2012
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- 10 April 2012, pp xi-xvi
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1 - Evidence across traditions
- John D. Jackson, University College Dublin, Sarah J. Summers, Universität Zürich
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- The Internationalisation of Criminal Evidence
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- 05 June 2012
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- 19 January 2012, pp 3-29
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Summary
Introduction: the convergence debate
Within the last 30 years there has been a renewal of interest among teachers and students in comparative criminal justice as a field of study. With growing pressure on legal systems to respond to the demands of globalisation and cosmopolitanism, penal law has become one of a growing number of areas of law that is engaging with comparative legal studies. Much of the debate has centred on whether or not these demands are driving legal systems towards convergence. A combination of pressures would seem to be supporting the convergence thesis within criminal justice. National legal systems plagued by common problems of rising crime, concern for victims and the growing cost and delay in processing cases through the courts would seem to have led to a willingness to seek ‘foreign’ solutions to similar problems. In addition to these internal pressures, there have been external pressures on states to find common transnational solutions to deal with the problems of organised crime and drug trafficking.
In addition to this, international terrorism and the growing ethnic and religious conflicts around the world pose a particular challenge for international law as to whether these problems can be resolved by international legal co- operation or whether as protagonists of the ‘war on terror’ would have it they are better met through the exercise of hegemonic power with international law being reduced to accommodate the demands of the most powerful states. Those who would seek to deal with these problems through international law need to develop common legal solutions. An example of this is the effort made by the international legal community to deal with those who have committed war crimes and crimes against humanity through international criminal tribunals applying international criminal law. But if this new international regime is to work successfully, there needs to be a consensus on the appropriate rules of evidence and procedure for holding such trials.
11 - Towards a theory of evidentiary defence rights
- John D. Jackson, University College Dublin, Sarah J. Summers, Universität Zürich
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- The Internationalisation of Criminal Evidence
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- 05 June 2012
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- 19 January 2012, pp 367-391
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Summary
Beyond tradition
This book has sketched a theory of positive evidentiary rights around the notion of effective defence participation which it has been argued is emerging, not always coherently, from international human rights law and within domestic and international criminal processes. The theory does not require systems to model their evidentiary processes upon any particular legal tradition. It has been argued that the principles of equality of arms and the right to adversarial procedure developed in particular by the ECtHR can be accommodated across the common law and civil law traditions. The development of these principles is better portrayed in terms of realigning and transforming the established procedural traditions of the common law and the civil law than as representing a convergence of the two traditions. So the notion of ‘adversarial procedure’ developed by the ECtHR does not require systems to organise procedural control entirely around the prosecution and defence with a passive judge or jury deciding cases purely upon the facts and arguments adduced by the parties. Indeed, one of the themes that emerges in the human rights jurisprudence is the importance of judicial activism in ensuring the fairness of the proceedings. At the same time, the notion of an active defence which has been increasingly stressed in the jurisprudence as important in the pre-trial process, as well as at trial, rubs against any old ‘inquisitorial’ notion of the court exclusively dominating the procedural action. In this final chapter, we assess the impact that a theory of evidentiary defence rights has on the established common law and civil law traditions and what prospects there are for such a theory taking hold in the future.
9 - Defence participation
- John D. Jackson, University College Dublin, Sarah J. Summers, Universität Zürich
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- The Internationalisation of Criminal Evidence
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- 05 June 2012
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- 19 January 2012, pp 285-324
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Summary
Introduction: legal representation and self-representation
We have seen how through concepts such as the equality of arms and the right to an adversarial procedure, human rights jurisprudence has been developing a theory of effective defence participation which not only allows for the participation of the accused in the criminal proceedings, but also gives institutional rights to the defence as a party entitled to be treated on an equal basis as the prosecution. These institutional rights have their foundation in what the ECtHR has described as the ‘minimum’ rights laid down in Article 6(3) of the ECHR and also set out in the other human rights instruments – the right to be informed of the charges, to have adequate time and facilities to prepare the defence, the right to defend oneself or to have the assistance of counsel, the right to test witness evidence and, finally, the right to the free assistance of an interpreter.
At the core of the right to defence participation lies the right to defend oneself in person or through legal assistance of one's own choosing. This right has been described as ‘practically absolute’, although as we saw in the last chapter there has been some uncertainty about the stage in the criminal process at which legal assistance can come to the aid of defendants. Built into the wording is a strong notion of individual participation by the accused. Defendants can choose to defend themselves or through legal assistance of their own choosing. The suggestion is that counsel is there at the personal choice and as the personal representative of the accused. In this sense, the right to legal assistance can be depicted as an expression of the principles of individual dignity and autonomy that have overlain so many of the individual rights in human rights instruments. Legal assistance serves to promote individual dignity by helping to alleviate the stress of facing charges and helping to supervise and control the activities of the law enforcement officers, ensuring that accused persons are treated properly. As well as acting in a protective capacity, counsel can also give expression to defendants’ participation more effectively than defendants themselves, provided they faithfully adhere to carrying out their clients’ instructions and act in accordance with their wishes.
Table of international cases
- John D. Jackson, University College Dublin, Sarah J. Summers, Universität Zürich
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- The Internationalisation of Criminal Evidence
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- 05 June 2012
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- 19 January 2012, pp xxii-xxxvi
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5 - Evidence in the international criminal tribunals
- John D. Jackson, University College Dublin, Sarah J. Summers, Universität Zürich
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- The Internationalisation of Criminal Evidence
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- 05 June 2012
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- 19 January 2012, pp 108-148
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Towards an international system of justice
In the last chapter we discussed the attempts that have been made to fashion a common law of criminal evidence within international human rights regimes and we argued that the European Court of Human Rights in particular has been developing within its jurisprudence a participatory model of proof that is rooted in both common and civil law traditions, but may be genuinely classified as sui generis. These regimes marked an important turning point for international law, as they shifted the focus away from the interests of states towards the interests of individuals. The individual rights theories that developed during the Enlightenment were re-invigorated within the international arena as the treatment of individuals by states became a matter of international concern. But these regimes were still state-centred in the sense that their rulings were concerned with whether states had met their obligations towards individuals, such as the obligation to ensure a fair trial. For our purposes, we have seen that they tolerated a fair degree of divergence between states as to how fair trials could be achieved. When international law took a further step towards recognising the significance of the individual by making individuals responsible for international crimes, however, agreement had to be reached not only on the principles of fair trial, but also on detailed rules of procedure and evidence for trying persons charged with such crimes.
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