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Cumulative environmental problems are complex, insidious, slow-motion tragedies that are all too common, from biodiversity loss, to urban air pollution, to environmental injustice. Taking an interdisciplinary, comparative and applied approach, this book offers a new framework for designing solutions using four integrated regulatory functions: Conceptualization, Information, Regulatory intervention and Coordination (the CIRCle Framework). Rules that deliver these functions can help us to clarify what we care about, reveal the cumulative threats to it and do something about those threats – together. Examples from around the world illustrate diverse legal approaches to each function and three major case studies from California, Australia and Italy provide deeper insights. Regulating a Thousand Cuts offers an optimistic, solution-oriented resource and a step-by-step guide to analysis for researchers, policymakers, regulators, law reformers and advocates. This title is also available as open access on Cambridge Core.
Everywhere one looks, one finds dynamic interacting systems: entities expressing and receiving signals between each other and acting and evolving accordingly over time. In this book, the authors give a new syntax for modeling such systems, describing a mathematical theory of interfaces and the way they connect. The discussion is guided by a rich mathematical structure called the category of polynomial functors. The authors synthesize current knowledge to provide a grounded introduction to the material, starting with set theory and building up to specific cases of category-theoretic concepts such as limits, adjunctions, monoidal products, closures, comonoids, comodules, and bicomodules. The text interleaves rigorous mathematical theory with concrete applications, providing detailed examples illustrated with graphical notation as well as exercises with solutions. Graduate students and scholars from a diverse array of backgrounds will appreciate this common language by which to study interactive systems categorically.
Over the past century, countries around the globe have empowered constitutional courts to safeguard the rule of law. But when can courts effectively perform this vital task? Drawing upon a series of survey experiments fielded in the United States, Germany, Hungary, and Poland, this book demonstrates that judicial independence is critical for judicial efficacy, showing that independent courts are uniquely capable of empowering citizens to punish executives who flout the rule of law, while also demonstrating that weak courts are unable to generate public support for upholding the rule of law. This important work concludes that, while judicial efficacy is neither universal nor automatic, courts-so long as they are viewed by the public as independent-can provide an effective check on executives and promote the rule of law.
Many AI development organizations advertise that they have offices of ethics that facilitate ethical AI. However, concerns have been raised that these offices are merely symbolic and do not actually promote ethics. We address the question of how we can know whether an organization is engaging in ethics washing in this way. We articulate an account of organizational power, and we argue that ethics offices that have power are not merely symbolic. Furthermore, we develop a framework for assessing whether an organization has an empowered ethics office—and, thus, is not ethics washing via a symbolic ethics office.
This study aimed to refine the content of a new patient-reported outcome (PRO) measure via cognitive interviewing techniques to assess the unique presentation of depressive symptoms in older adults with cancer (OACs).
Methods
OACs (≥ 70years) with a history of a depressive disorder were administered a draft measure of the Older Adults with Cancer – Depression (OAC-D) Scale, then participated in a semi-structured cognitive interview to provide feedback on the appropriateness, comprehensibility, and overall acceptability of measure. Interviews were audio-recorded and transcribed, and qualitative methods guided revision of scale content and structure.
Results
OACs (N = 10) with a range of cancer diagnoses completed cognitive interviews. Participants felt that the draft measure took a reasonable amount of time to answer and was easily understandable. They favored having item prompts and response anchors repeated with each item for ease of completion, and they helped identify phrasing and wording of key terms consistent with the authors’ intended constructs. From this feedback, a revised version of the OAC-D was created.
Significance of results
The OAC-D Scale is the first PRO developed specifically for use with OACs. The use of expert and patient input and rigorous cognitive interviewing methods provides a conceptually accurate means of assessing the unique symptom experience of OACs with depression.
Objectives/Goals: A key strategy in generating a protective HIV vaccine is the elicitation of broadly neutralizing antibodies (bnAbs), capable of neutralizing a large diversity of HIV-1 isolates. The goal of this study is to identify molecular signatures of HIV bnAb development early in life, to guide the development of a successful pediatric HIV vaccine strategy. Methods/Study Population: We previously defined HIV neutralization breadth in 40 ART-naive children living with HIV. Single-cell RNAseq was performed utilizing peripheral blood mononuclear cells (PBMCs) from the top 5 children with highest neutralization breadth scores and compared their transcriptome to that of PBMCs from 5 children that did not develop neutralization breadth within the first three years of life. Additionally, we incorporated analysis of PBMCs from 5 healthy uninfected children, matched to our experimental groups by race, ethnicity, and gender. Results/Anticipated Results: We expect that a distinct host transcriptional profile is associated with the development of HIV-specific antibody neutralization breadth in early life. Discussion/Significance of Impact: Identifying immune cell transcriptional profiles associated with neutralization breadth will lead to more targeted vaccine approaches for eliciting the appropriate B cell responses and provide an invaluable screening tool allowing early identification of vaccine candidates with the potential to induce bnAbs.
To evaluate the impact of a mobile-app-based central line-associated bloodstream infection (CLABSI) prevention program in oncology clinic patients with peripherally inserted central catheters (PICCs).
Design:
Pre-post prospective cohort study with baseline (July 2015–December 2016), phase-in (January 2017–April 2017), and intervention (May 2017–November 2018). Generalized linear mixed models compared intervention with baseline frequency of localized inflammation/infection and dressing peeling. Cox proportional hazards models compared days-to-removal of lines with localized inflammation/infection. Chi-square test compared bacteremia rates before and after intervention.
Setting:
Oncology clinic at a large medical center.
Patients:
Oncology clinic adult patients with PICCs.
Intervention:
CLABSI prevention program consisting of an actionable scoring system for identifying insertion site infection/inflammation coupled with a mobile-app enabling photo-assessments and automated physician alerting for remote response.
Results:
We completed 5,343 assessments of 569 PICCs in 401 patients (baseline: 2,924 assessments, 300 PICCs, 216 patients; intervention: 2,419 assessments, 269 PICCs, 185 patients). The intervention was associated with a 92% lower likelihood of having a dressing with peeling (OR 0.08, 95%CI 0.04-0.17, P < 0.001), 53% lower local inflammation/infection (OR 0.47, 95%CI 0.27-0.84, P < 0.011), and 24% (non-significant) lower CLABSI rates (P = .63). Physician mobile-app alerting and response enabled 80% lower risk of lines remaining in place after inflammation/infection was identified (HR 0.20, 95%CI:0.14-0.30, P < 0.001) and 85% faster removal of infected lines from mean (SD) 11.1 (9.7) to 1.7 (2.4) days.
Conclusions:
A mobile-app-based CLABSI prevention program decreased frequency of inflamed/infected central line insertion sites and increased speed of removal when inflammation/infection was found.
One of the earliest discoveries of Permo-Carboniferous terrestrial vertebrates in North America occurred in 1875 along Horseshoe Bend, a cutbank on the Salt Fork of the Vermilion River west of Danville, Vermilion County, east-central Illinois. The discovery was soon eclipsed by the description of similar but much more complete remains from the Lower Permian of Texas in 1878. The deposit itself was obliterated by slumping and erosion in the earliest 1900s and has not been collected since despite repeated efforts. Previously unreported outcrop records and subsurface data indicate that the deposit originated as a paleochannel fill in the Inglefield Sandstone Member of the Patoka Formation, which underlies the Macoupin Limestone Member (early Missourian Stage of the Midcontinent, early Kasimovian Stage of global Carboniferous time scale). In addition to aquatic to terrestrial tetrapods, teeth of lungfishes (Sagenodus Owen, 1867, Conchopoma Cope, 1877a, Gnathorhiza Cope, 1883a) and teeth, occipital spines, and coprolites of a xenacanth shark (Orthacanthus Agassiz, 1838) are known from Horseshoe Bend. The teeth of the marine petalodont shark Janassa Münster, 1839, also are present in the collection but presumed to have been derived from one of the beds on the cutbank that produced brackish to marine invertebrate fossils. Alhough not diverse, the tetrapod assemblage is significant in that it contains the oldest diplocaulid amphibian (Diplocaulus salamandroides Cope, 1877a), fragmentary remains of the oldest diadectid and limnoscelid stem reptiles, and possibly the oldest captorhinid eureptile, all of which have not been adequately described. The ophiacodontid synapsid Clepsydrops Cope, 1875, is the most common fossil at Danville, which could be an artifact of primitive collecting methods that did not promote the recovery of articulated material. An accurate stratigraphic placement of the Horseshoe Bend deposit and a review of other late Carboniferous tetrapod localities reveals that this important Illinois locality combines an overlooked vanguard of terrestrial taxa regarded as Permo-Carboniferous (Kasimovian-Asselian) and amphibious to aquatic forms known from older, Moscovian deposits.
Understanding complex three-dimensional cardiac structures is the key to knowing CHD. Many learners have limited access to cadaveric specimens, and most alternative teaching modalities are two-dimensional. Therefore, we have developed virtual cardiac models using photogrammetry of actual heart specimens to address this educational need.
Methods:
A descriptive study was conducted at a single institution during a week-long cardiac morphology conference in October 2022 and 2023. Conference attendees viewed virtual cardiac models via laptop screen and virtual reality headset. Learners were surveyed on their opinions of the virtual models and their perceived effectiveness compared to existing educational materials.
Results:
Forty-six learners completed the survey. Participants reported the virtual cardiac models to be more effective than textbook diagrams (60%), and equally or more effective compared to didactic teaching (78%) and specimen videos (78%). Approximately half of participants (54%) found the virtual models to be less effective than hands-on cadaveric specimen inspection. Attitudes towards the virtual specimens were overall positive with most responders finding the tool engaging (87%) and enjoyable (85%). A majority reported that the models deepened their understanding of cardiac morphology (79%) and that they would recommend them to other trainees (87%).
Conclusions:
This study demonstrates that a novel teaching tool, virtual cardiac specimens, is equivalent to or more effective than many current materials for learning cardiac morphology. While they may not replace direct cadaveric specimen review, virtual models are an engaging alternative with the ability to reach a wider audience.
This chapter suggests that the papacy dealt with Protestantism in various ways. It condemned the forty-one propositions of Martin Luther and then waited for the Council of Trent to condemn others. It used the institutions of preventive press censorship and of various inquisitions to check heresy. It sought the support of Christian rulers to prevent its spread, sending nuncios and legates to the rulers of the Holy Roman Empire, France, England, Scotland, Sweden, Denmark, and Poland–Lithuania to urge them to suppress heresy and to secure their loyalty by negotiating agreements on Church appointments and shared revenues and by offering military aid, efforts that had mixed success, or failed. Religious orders such as the Jesuits and Capuchins were also enlisted in the struggle. Leading Protestant reformers came to see the papacy as the Antichrist or foreign usurper.
This research builds on the work of D.K. Gode and Shyam Sunder who demonstrated the existence of a strong relationship between market institutions and the ability of markets to seek equilibrium—even when the agents themselves have limited intelligence and behave with substantial randomness. The question posed is whether or not market institutions account for the operation of the law of supply and demand in markets populated by humans with no role required of human rationality. Are institutions responsible for the operations of the law of supply and demand or are behavioral principles also at work? Experiments with humans and simulations with robots both conducted in conditions in which major institutional and structural aids to convergence were removed, produced clear answers. Human markets converge, while robot markets do not. The structural and institutional features certainly facilitate convergence under conditions of substantial irrationality, but they are not necessary for convergence in markets in which agents have the rationality of humans.
As in Roberson's analysis of popular songs, Christopher T. Nelson shows how memories of war shape popular culture in Okinawa today—in Nelson's case in the context of community-based dance performances known as eisā. Today eisā is the most widespread and widely recognized community activity practiced in contemporary Okinawa. The Koza Riot that Nelson refers to occurred during the evening of December 20-21, 1970, in what was then a red light district caering primarily to American military personnel outside Kadena Air Force Base. The rioting was precipitated by an incident in which a car driven by an intoxicated American soldier struck an Okinawan man. Efforts by U.S. Military Police to extricate the soldier in question sparked eight hours of street fighting between hundreds of MPs and thousands of local Okinawan residents, resulting in dozens of injuries and large-scale property damage. Most observers interpreted the Koza Riot as an expression of widespread simmering resentment among the local population against the U.S. military presence.
Health technology assessment (HTA) is a critical part of healthcare decision making in many countries. Changes in Methods and Processes (M&P) of HTA agencies can affect the time and degree of patient access to treatments. Published literature focuses on the different M&P adopted by HTA agencies, rather than on how these have come about over time. Our study investigates key HTA reforms and explores their drivers and interdependencies in a set of HTA agencies in Europe, Asia-Pacific, and North America.
Methods
We conducted a targeted literature review on M&P guidelines and subsequent changes to those, for 14 HTA agencies. We supplemented and validated initial findings with 29 semi-structured interviews with country-specific experts. We used analytical tools to create process maps, proactivity and influence networks, and clusters of HTA agencies.
Results
We found that processes leading to M&P reforms follow similar steps across HTA agencies. The three most important drivers to reforms were HTA practice and guidelines in other countries; the healthcare policy, legal, and political context within the agency’s country; and experience of challenges in the assessment by the HTA body itself. International collaborations have the potential to accelerate the evolution of HTA systems and the implementation of reforms.
Conclusion
We identified PBAC (Australia), CDA-AMC (Canada), NICE (England), IQWiG (Germany), and ZIN (the Netherlands) as HTA agencies that are catalysts of HTA reforms as well as internationally influential. International collaborations may represent a useful route to accelerate changes as long as they ensure wide stakeholder engagement at an early stage.
To improve early intervention and personalise treatment for individuals early on the psychosis continuum, a greater understanding of symptom dynamics is required. We address this by identifying and evaluating the movement between empirically derived attenuated psychotic symptomatic substates—clusters of symptoms that occur within individuals over time.
Methods
Data came from a 90-day daily diary study evaluating attenuated psychotic and affective symptoms. The sample included 96 individuals aged 18–35 on the psychosis continuum, divided into four subgroups of increasing severity based on their psychometric risk of psychosis, with the fourth meeting ultra-high risk (UHR) criteria. A multilevel hidden Markov modelling (HMM) approach was used to characterise and determine the probability of switching between symptomatic substates. Individual substate trajectories and time spent in each substate were subsequently assessed.
Results
Four substates of increasing psychopathological severity were identified: (1) low-grade affective symptoms with negligible psychotic symptoms; (2) low levels of nonbizarre ideas with moderate affective symptoms; (3) low levels of nonbizarre ideas and unusual thought content, with moderate affective symptoms; and (4) moderate levels of nonbizarre ideas, unusual thought content, and affective symptoms. Perceptual disturbances predominantly occurred within the third and fourth substates. UHR individuals had a reduced probability of switching out of the two most severe substates.
Conclusions
Findings suggest that individuals reporting unusual thought content, rather than nonbizarre ideas in isolation, may exhibit symptom dynamics with greater psychopathological severity. Individuals at a higher risk of psychosis exhibited persistently severe symptom dynamics, indicating a potential reduction in psychological flexibility.
This essay argues that what distinguishes a negatively valenced phenomenal experience from suffering is an ability to make meaning of the experience. In this sense, intellectual ability influences the extent and nature of suffering. But this connection is not a straightforward one, since intellectual ability cuts both ways. On the one hand, those with higher levels of intellectual functioning are better able to make meaning of negative experiences, thereby reducing their suffering. On the other, intellectual ability can influence the depth and breadth of one’s negative experiences, thereby increasing suffering. This means that we cannot make any assumptions about a person’s susceptibility to suffering based on their level of intellectual functioning alone.
The interstage period is a critical phase for single ventricle infants due to their fragile cardiovascular state. Infants often experience medical and feeding challenges during this period, resulting in caregiver stress. We completed a quality improvement project at Children’s Healthcare of Atlanta to understand these challenges to inform targeted interventions.
Methods:
This single-center project included a medical chart review and a cross-sectional caregiver survey. Data were collected on patient and caregiver demographics and clinical variables. Feeding outcomes were assessed using the Pediatric Functional Oral Intake Scale. Caregiver impact was measured using the Feeding/Swallowing Impact Survey.
Results:
The project included 15 single ventricle patients with a mean (standard deviation) age of 151.73(25.92) days at the time of the second-stage palliation. Forty percent of patients experienced at least one readmission, primarily due to feeding intolerance (20%) and desaturations (26.7%). Milk protein allergy (26.9%) was the most common medical complication, followed by interstage unplanned reinterventions. Pediatric Functional Oral Intake Scale scores demonstrated that 33% consumed minimal volumes or no oral intake at the time of the bidirectional Glenn, and 93.3% of patients did not receive outpatient feeding services during the interstage. Caregiver stress scores resulted in mean scores (standard deviation) of 2.23(1.54), with the highest impact on daily activities. All caregivers affirmed the need for a dedicated multidisciplinary clinic.
Conclusion:
The interstage period for single ventricle patients poses significant medical and feeding challenges, resulting in caregiver stress. Comprehensive, multidisciplinary feeding support during the interstage period may improve patient outcomes and alleviate caregiver burden.
The number of conflict-affected individuals is climbing. Humanitarian organizations are increasingly needed to provide medical care when governments lack capacity to care for affected communities. While the World Health Organization’s (WHO) Emergency Medical Team (EMT) initiative provides a verification process for organizations seeking to provide health care in the setting of various disasters, it does not address the unique operational challenges of deployment into conflict-affected communities. One solution is the implementation of a supplemental process similar to current verification procedures, wherein the WHO adopts a policy encouraging teams to complete an additional conflict-oriented verification, based on WHO Red Book recommendations, if they plan to operate in conflict settings The EMT initiative possesses expertise and the convening authority to drive international standards for care provision during health emergencies and is the obvious platform to create a rigorous process to ensure that EMTs in conflict zones are appropriately trained, vetted, and accountable.
A specimen of Prionotus punctatus was caught in Bahía Engaño, Chubut Province, Patagonia, Argentina. This extends the known distribution by 900 km and a 5.5° further south from its previous southernmost record. This record increases the number of species of the genus Prionotus and the fish diversity of central Patagonia. The presence of P. punctatus along with other recent reports of fish of tropical and subtropical lineages in central Patagonia adds new evidence on the ongoing tropicalization of the Patagonian Sea.