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Acute coronary syndrome (ACS) may not be excluded on initial evaluation and testing because of the protean presentations, up to 1/3 of patients ultimately diagnosed with ACS do not have chest pain and the limitations of existing technology. Patients with confirmed ACS or high risk should be admitted. Low-risk patients can be safely discharged from the emergency department (ED). Observation units (OUs) provide an intermediate location for evaluation and monitoring in patients with low to moderate suspicion for ACS, where serial ECGs, cardiac biomarkers, stress testing, anatomical imaging, etc. can be done.
During excavations of a Roman villa at Fordham, Essex, a remarkable series of decorated bone and antler veneer plaques were recovered from villa destruction deposits. They are datable to the later fourth or fifth centuries a.d. and probably once adorned a casket holding bathing equipment and jewellery. Spread through the three main rooms of the villa, fragments were recovered from at least 10 metres apart, so the object is likely already to have been broken when deposited. The plaques are decorated with ‘late antique’ style figural, zoomorphic, vegetal and architectural motifs on a cross-hatched background, with the best-preserved design probably relating to female bathing.
Changing practice patterns caused by the pandemic have created an urgent need for guidance in prescribing stimulants using telepsychiatry for attention-deficit hyperactivity disorder (ADHD). A notable spike in the prescribing of stimulants accompanied the suspension of the Ryan Haight Act, allowing the prescribing of stimulants without a face-to-face meeting. Competing forces both for and against prescribing ADHD stimulants by telepsychiatry have emerged, requiring guidelines to balance these factors. On the one hand, factors weighing in favor of increasing the availability of treatment for ADHD via telepsychiatry include enhanced access to care, reduction in the large number of untreated cases, and prevention of the known adverse outcomes of untreated ADHD. On the other hand, factors in favor of limiting telepsychiatry for ADHD include mitigating the possibility of exploiting telepsychiatry for profit or for misuse, abuse, and diversion of stimulants. This Expert Consensus Group has developed numerous specific guidelines and advocates for some flexibility in allowing telepsychiatry evaluations and treatment without an in-person evaluation to continue. These guidelines also recognize the need to give greater scrutiny to certain subpopulations, such as young adults without a prior diagnosis or treatment of ADHD who request immediate-release stimulants, which should increase the suspicion of possible medication diversion, misuse, or abuse. In such cases, nonstimulants, controlled-release stimulants, or psychosocial interventions should be prioritized. We encourage the use of outside informants to support the history, the use of rating scales, and having access to a hybrid model of both in-person and remote treatment.
An article published in 2018 by J.D. Hamilton gained significant attention due to its provocative title, “Why you should never use the Hodrick-Prescott filter.” Additionally, an alternative method for detrending, the Hamilton regression filter (HRF), was introduced. His work was frequently interpreted as a proposal to substitute the Hodrick–Prescott (HP) filter with HRF, therefore utilizing and understanding it similarly as HP detrending. This research disputes this perspective, particularly in relation to quarterly business cycle data on aggregate output. Focusing on economic fluctuations in the United States, this study generates a large amount of artificial data that follow a known pattern and include both a trend and cyclical component. The objective is to assess the effectiveness of a certain detrending approach in accurately identifying the real decomposition of the data. In addition to the standard HP smoothing parameter of $\lambda = 1600$, the study also examines values of $\lambda ^{\star }$ from earlier research that are seven to twelve times greater. Based on three unique statistical measures of the discrepancy between the estimated and real trends, it is evident that both versions of HP significantly surpass those of HRF. Additionally, HP with $\lambda ^{\star }$ consistently outperforms HP-1600.
End members and species defined with permissible ranges of composition are presented for the true micas, the brittle micas and the interlayer-cation-deficient micas. The determination of the crystallochemical formula for different available chemical data is outlined, and a system of modifiers and suffixes is given to allow the expression of unusual chemical substitutions or polytypic stacking arrangements. Tables of mica synonyms, varieties, ill-defined materials and a list of names formerly or erroneously used for micas are presented. The Mica Subcommittee was appointed by the Commission on New Minerals and Mineral Names (“Commission”) of the International Mineralogical Association (IMA). The definitions and recommendations presented were approved by the Commission.
Modern psychometric methods make it possible to eliminate nonperforming items and reduce measurement error. Application of these methods to existing outcome measures can reduce variability in scores, and may increase treatment effect sizes in depression treatment trials.
Aims
We aim to determine whether using confirmatory factor analysis techniques can provide better estimates of the true effects of treatments, by conducting secondary analyses of individual patient data from randomised trials of antidepressant therapies.
Method
We will access individual patient data from antidepressant treatment trials through Clinicalstudydatarequest.com and Vivli.org, specifically targeting studies that used the Hamilton Rating Scale for Depression (HRSD) as the outcome measure. Exploratory and confirmatory factor analytic approaches will be used to determine pre-treatment (baseline) and post-treatment models of depression, in terms of the number of factors and weighted scores of each item. Differences in the derived factor scores between baseline and outcome measurements will yield an effect size for factor-informed depression change. The difference between the factor-informed effect size and each original trial effect size, calculated with total HRSD-17 scores, will be determined, and the differences modelled with meta-analytic approaches. Risk differences for proportions of patients who achieved remission will also be evaluated. Furthermore, measurement invariance methods will be used to assess potential gender differences.
Conclusions
Our approach will determine whether adopting advanced psychometric analyses can improve precision and better estimate effect sizes in antidepressant treatment trials. The proposed methods could have implications for future trials and other types of studies that use patient-reported outcome measures.
The Falerii Novi Project represents a newly formed archaeological initiative to explore the Roman city of Falerii Novi. The project forms a collaboration of the British School at Rome with a multinational team of partner institutions. Thanks to a rich legacy of geophysical work on both the site and its territory, Falerii Novi presents an exceptional opportunity to advance understanding of urbanism in ancient and medieval Italy. The Falerii Novi Project employs a range of methodologies, integrating continued site-scale survey with new campaigns of stratigraphic excavation, archival research and environmental archaeology. The project aims to present a more expansive and holistic urban history of this key Tiber Valley settlement by focusing on long-run socio-economic processes both within Falerii Novi and as they linked the city to its wider landscape.
Excess unabsorbed iron in the gastrointestinal tract may select for enteric pathogens and increase the incidence and severity of infectious disease. Aspergillus oryzae (Ao) is a filamentous fungus that has the ability to accumulate and store large amounts of iron, and when used as a supplement or fortificant, has similar absorption to ferrous sulphate (FeSO4) in humans. The objective of this study was to determine the effect of iron-enriched Ao (Ao iron) compared with FeSO4 on iron accumulation, growth and motility of the Gram-negative enteric pathogen, S. Typhimurium. S. Typhimurium was cultured in media containing no added iron or 1 μM elemental iron as either Ao iron or FeSO4. S. Typhimurium cultured with FeSO4 accumulated more iron than those cultured with Ao iron. Genes regulated by the iron-activated transcriptional repressor, Fur, did not differ between control and Ao iron, but decreased in S. Typhimurium cultured with FeSO4 compared with both groups. Growth of S. Typhimurium was greater when cultured with FeSO4 compared with Ao iron and control. S. Typhimurium swam faster, had greater acceleration and travelled further when cultured with FeSO4 compared with Ao iron and control; swim speed, acceleration and distance travelled did not differ between Ao iron and control. These findings provide evidence that Ao iron reduces the virulence of a common enteric pathogen in vitro. Further research is required to determine whether iron-enriched Ao is a suitable iron supplement to improve iron delivery in areas with a high infection burden.
Many studies have investigated why countries adopt gender quotas for their elections. In this article, we answer a different question: why do political parties comply with gender quotas when the costs of noncompliance are absent or minimal? To answer this question, we analyze data from 1,600 party lists and 106 parties competing across 121 cities in the 2015 municipal elections in Ukraine. Our subnational approach tests whether contextual factors flagged by the broader gender literature explain variation in compliance across localities. The results of our models support our contention that Ukrainian political parties behaved strategically in terms of nominations and quota compliance. We find that urbanization and female incumbency fueled quota compliance. Parties, however, were less likely to comply with quotas in cities with more Ukrainian speakers. We suggest that the politics of memory explain this outcome, as Ukrainian speakers are more likely to remember of the costs of Soviet rule.
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. It has been known for some time as a both a reproductive and a metabolic disorder but more recently, mainly as a result of large longitudinal population-based studies, is becoming recognized as a complex multisystem disorder with comorbidities and long-term health implications. PCOS is associated not only with reproductive and metabolic features but also with cardiovascular abnormalities, psychological illness and endometrial cancer. Data are also emerging about possible long-term health consequences for the offspring of women with PCOS. Their children are more likely to be obese with metabolic disorders and are more likely to develop neurodevelopmental or psychiatric disorders. In this chapter, the long-term health consequences of PCOS for women and their offspring are described, together with a discussion on how they should best be managed.
This is a case of an infant with unilateral discontinuous right pulmonary artery. Cardiac catheterisation with pulmonary wedge injection diagnosed the anomaly and aided in surgical planning. The patient underwent semi-autologous surgical repair utilising an autologous main pulmonary artery flap. One month following discharge, he underwent successful balloon dilation of the residual stenosis and was discharged the same day.
Health professionals in China tend to avoid open communication with terminally ill cancer patients concerning their diagnosis and prognosis. This review aims to explore Chinese cultural beliefs and attitudes concerning disclosure and death among health professionals and cancer patients in China and to investigate preferences of terminally ill cancer patients for a “good death.”
Method
A narrative literature review was conducted in May 2020 on MEDLINE, EMBASE, and WEB OF SCIENCE to include all studies with clear study design which presented its own study data or referred to data within underlying studies, published between January 2000 and May 2020, having cancer patients and/or healthcare professionals as participants, conducted in Mainland China, Hong Kong, or Taiwan and containing relevant data concerning “medical disclosure” or “good death.” Quality assessment of publications was conducted using the NIH and CASP checklists.
Results
Primary database search revealed a total of 108 papers of which 9 were ultimately included. The additional hand search led to the inclusion of eight further papers. In total, there were 11 quantitative studies, 4 qualitative studies and 2 literature reviews included in this review. Our findings indicated that most terminally ill cancer patients in China want to know the truth about their diagnosis and prognosis and preferred to be informed by their doctors. Terminally ill cancer patients valued a good relationship with family and medical staff as well as being respected as an individual and wanted to be able to prepare for death.
Significance of results
Terminally ill cancer patients in China often have a substantial need for information about their condition while their preferences are widely consistent with those in Western societies. Training for health professionals needs to focus on communication skills in order to overcome barriers in patient interaction.
A recent genome-wide association study (GWAS) identified 12 independent loci significantly associated with attention-deficit/hyperactivity disorder (ADHD). Polygenic risk scores (PRS), derived from the GWAS, can be used to assess genetic overlap between ADHD and other traits. Using ADHD samples from several international sites, we derived PRS for ADHD from the recent GWAS to test whether genetic variants that contribute to ADHD also influence two cognitive functions that show strong association with ADHD: attention regulation and response inhibition, captured by reaction time variability (RTV) and commission errors (CE).
Methods
The discovery GWAS included 19 099 ADHD cases and 34 194 control participants. The combined target sample included 845 people with ADHD (age: 8–40 years). RTV and CE were available from reaction time and response inhibition tasks. ADHD PRS were calculated from the GWAS using a leave-one-study-out approach. Regression analyses were run to investigate whether ADHD PRS were associated with CE and RTV. Results across sites were combined via random effect meta-analyses.
Results
When combining the studies in meta-analyses, results were significant for RTV (R2 = 0.011, β = 0.088, p = 0.02) but not for CE (R2 = 0.011, β = 0.013, p = 0.732). No significant association was found between ADHD PRS and RTV or CE in any sample individually (p > 0.10).
Conclusions
We detected a significant association between PRS for ADHD and RTV (but not CE) in individuals with ADHD, suggesting that common genetic risk variants for ADHD influence attention regulation.
The novel severe acute respiratory coronavirus virus 2 (SARS-CoV-2) was first reported in Wuhan, China, in December 2019 and is notable for being highly contagious and potentially lethal; and SARS-CoV-2 is mainly spread by droplet transmission. The US healthcare system’s response to the COVID-19 pandemic has been challenged by a shortage of personal protective equipment (PPE), especially N95 respirators. Restricted use, reuse, and sanitation of PPE have been widely adopted to provide protection for frontline healthcare workers caring for often critically ill and highly contagious patients. Here, we describe our validated process for N95 respirator sanitation.
Design:
Process development, validation, and implementation.
Setting:
Level 1, urban, academic, medical center.
Methods:
A multidisciplinary team developed a novel evidence-based process for N95 respirator reprocessing and sanitation using ultraviolet (UV) light. Dose measurement, structural integrity, moisture content, particle filtration, fit testing, and environmental testing were performed for both quality control and validation of the process.
Results:
The process achieved UV light dosing for sanitation while maintaining the functional and structural integrity of the N95 respirators, with a daily potential throughput capacity of ∼12,000 masks. This process has supported our health system to provide respiratory PPE to all frontline team members.
Conclusions:
This novel method of N95 respirator sanitation can safely enable reuse of the N95 respirators essential for healthcare workers caring for patients with COVID-19. Our high-throughput process can extend local supplies of this critical PPE until the national supply is replenished.
Antarctica's ice shelves modulate the grounded ice flow, and weakening of ice shelves due to climate forcing will decrease their ‘buttressing’ effect, causing a response in the grounded ice. While the processes governing ice-shelf weakening are complex, uncertainties in the response of the grounded ice sheet are also difficult to assess. The Antarctic BUttressing Model Intercomparison Project (ABUMIP) compares ice-sheet model responses to decrease in buttressing by investigating the ‘end-member’ scenario of total and sustained loss of ice shelves. Although unrealistic, this scenario enables gauging the sensitivity of an ensemble of 15 ice-sheet models to a total loss of buttressing, hence exhibiting the full potential of marine ice-sheet instability. All models predict that this scenario leads to multi-metre (1–12 m) sea-level rise over 500 years from present day. West Antarctic ice sheet collapse alone leads to a 1.91–5.08 m sea-level rise due to the marine ice-sheet instability. Mass loss rates are a strong function of the sliding/friction law, with plastic laws cause a further destabilization of the Aurora and Wilkes Subglacial Basins, East Antarctica. Improvements to marine ice-sheet models have greatly reduced variability between modelled ice-sheet responses to extreme ice-shelf loss, e.g. compared to the SeaRISE assessments.
China is home to one-fifth of the world's population. In the setting of a growing and aging population as well as the designation of palliative care access as a human right in 2013, the implementation of palliative care in China gains special importance. Palliative care education is an important precondition to ensure a nationwide access to palliative care. This systematic review details the status of under- and postgraduate palliative care education in China, examining both the students’ and physicians’ perception, knowledge, and skills in palliative care, and the available educational interventions and programs.
Method
Four databases were searched in September 2018, using considered search terms. Titles, abstracts, and, if necessary, full texts were scanned to identify publications matching the inclusion criteria.
Results
Nine publications were included. They revealed six findings: palliative care education is lacking in both under- and postgraduate medical education, only a few programs exist. Palliative care as a concept is well known, detailed knowledge, and practical skills are less developed. Chinese physicians consider palliative care an important field to be developed in cancer care, yet the majority of healthcare professionals are not willing to work in palliative care services. Communication should be a main emphasis in palliative care education, especially in undergraduate training. Finally, there is no highly qualified research on under- or postgraduate palliative care education in Mainland China.
Significance of results
These findings suggest that palliative care education in China is in demand and should be systematically integrated into medical education. Further research on the topic is urgently needed.
We analysed thirty-five 400-m2 plots encompassing forest, savanna and intermediate vegetation types in an ecotonal area in Ghana, West Africa. Across all plots, fire frequency was over a period of 15 years relatively uniform (once in 2–4 years). Although woodlands were dominated by species typically associated with savanna-type formations, and with forest formations dominated by species usually associated with closed canopies, these associations were non-obligatory and with a discrete non-specialized species grouping also identified. Across all plots, crown area index, stem basal area and above-ground biomass were positively associated with higher soil exchangeable potassium and silt contents: this supporting recent suggestions of interplays between potassium and soil water storage potential as a significant influence on tropical vegetation structure. We also found an average NDVI cover increase of ~0.15% year−1 (1984–2011) with plots dominated by non-specialized species increasing more than those dominated by either forest- or savanna-affiliated species. Our results challenge the traditional view of a simple forest vs. savanna dichotomy controlled by fire, and with our newly identified third non-specialized species grouping also potentially important in understanding ecotonal responses to climate change.