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Transition to psychosis rates within ultra-high risk (UHR) services have been declining. It may be possible to ‘enrich’ UHR cohorts based on the environmental characteristics seen more commonly in first-episode psychosis cohorts. This study aimed to determine whether transition rates varied according to the accumulated exposure to environmental risk factors at the individual (migrant status, asylum seeker/refugee status, indigenous population, cannabis/methamphetamine use), family (family history or parental separation), and neighborhood (population density, social deprivation, and fragmentation) level.
Methods
The study included UHR people aged 15–24 who attended the PACE clinic from 2012 to 2016. Cox proportional hazards models (frequentist and Bayesian) were used to assess the association between individual and accumulated factors and transition to psychosis. UHR status and transition was determined using the CAARMS. Benjamini–Hochberg was used to correct for multiple comparisons in frequentist analyses.
Results
Of the 461 young people included, 55.5% were female and median follow-up was 307 days (IQR: 188–557) and 17.6% (n = 81) transitioned to a psychotic disorder. The proportion who transitioned increased incrementally according to the number of individual-level risk factors present (HR = 1.51, 95% CIs 1.19–1.93, p < 0.001, pcorr = 0.01). The number of family- and neighborhood-level exposures did not increase transition risk (p > 0.05). Cannabis use was the only specific risk factor significantly associated with transition (HR = 1.89, 95% CIs 1.22–2.93, pcorr = 0.03, BF = 6.74).
Conclusions
There is a dose–response relationship between exposure to individual-level psychosis-related environmental risk factors and transition risk in UHR patients. If replicated, this could be incorporated into a novel approach to identifying the highest-risk individuals within clinical services.
Modified Mini-Mental State Examination (3MSE) is often used to screen for dementia, but little is known about psychometric validity in American Indians.
Methods:
We recruited 818 American Indians aged 65–95 for 3MSE examinations in 2010–2013; 403 returned for a repeat examination in 2017–2019. Analyses included standard psychometrics inferences for interpretation, generalizability, and extrapolation: factor analysis; internal consistency-reliability; test-retest score stability; multiple indicator multiple cause structural equation models.
Results:
This cohort was mean age 73, majority female, mean 12 years education, and majority bilingual. The 4-factor and 2nd-order models fit best, with subfactors for orientation and visuo-construction (OVC), language and executive functioning (LEF), psychomotor and working memory (PMWM), verbal and episodic memory (VEM). Factor structure was supported for both research and clinical interpretation, and factor loadings were moderate to high. Scores were generally consistent over mean 7 years. Younger participants performed better in overall scores, but not in individual factors. Males performed better on OVC and LEF, females better on PMWM. Those with more education performed better on LEF and worse on OVC; the converse was true for bilinguals. All differences were significant, but small.
Conclusion:
These findings support use of 3MSE for individual interpretation in clinic and research among American Indians, with moderate consistency, stability, reliability over time. Observed extrapolations across age, sex, education, and bilingual groups suggest some important contextual differences may exist.
The goal of the Patient-Centered Outcomes Research Partnership was to prepare health care professionals and researchers to conduct patient-centered outcomes and comparative effectiveness research (CER). Substantial evidence gaps, heterogeneous health care systems, and decision-making challenges in the USA underscore the need for evidence-based strategies.
Methods:
We engaged five community-based health care organizations that serve diverse and underrepresented patient populations from Hawai’i to Minnesota. Each partner nominated two in-house scholars to participate in the 2-year program. The program focused on seven competencies pertinent to patient-centered outcomes and CER. It combined in-person and experiential learning with asynchronous, online education, and created adaptive, pragmatic learning opportunities and a Summer Institute. Metrics included the Clinical Research Appraisal Inventory (CRAI), a tool designed to assess research self-efficacy and clinical research skills across 10 domains.
Results:
We trained 31 scholars in 3 cohorts. Mean scores in nine domains of the CRAI improved; greater improvement was observed from the beginning to the midpoint than from the midpoint to conclusion of the program. Across all three cohorts, mean scores on 52 items (100%) increased (p ≤ 0.01), and 91% of scholars reported the program improved their skills moderately/significantly. Satisfaction with the program was high (91%).
Conclusions:
Investigators that conduct patient-centered outcomes and CER must know how to collaborate with regional health care systems to identify priorities; pose questions; design, conduct, and disseminate observational and experimental research; and transform knowledge into practical clinical applications. Training programs such as ours can facilitate such collaborations.
In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non–ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans’ Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.
We present an unusual case of concordant ventriculoarterial connections, subpulmonary infundibulum, and parallel arterial trunks. This case was complicated by extreme pulmonary artery tortuosity and low arching aorta causing severe tracheal compression. We discuss the difficulty in prenatal diagnosis, necessity for advanced imaging postnatally, and associated airway complications.
The river zonation hypothesis predicts that abiotic and biotic conditions along riparian gradients drive variation in animal communities. Glass frogs are a diverse group of Neotropical anurans that use riparian habitats exclusively for oviposition and larval development, but little is known about how glass frog communities are distributed across riparian gradients. Here, we measured glass frog community assembly across a gradient of riparian habitats from first- to fifth-order streams at La Selva Biological Station, Costa Rica. We performed repeated nocturnal frog calling surveys and built occupancy and N-mixture abundance models to test for varying patterns of species occupancy, community assembly, species richness (α-diversity) and species turnover (ß-diversity). We observed significant differences in patterns of species occupancy and community assembly across a stream-order gradient: occupancy of two species increased with stream order (Teratohyla pulverata, Hyalinobatrachium fleischmanni), one species decreased (Teratohyla spinosa), and one species did not vary (Espadarana prosoblepon). We evaluated four a priori hypotheses describing how α- and ß-diversity of centrolenids are shaped across the riparian gradient; our data were most consistent with a pattern of nested assemblages and increasing species richness along the riparian gradient. Species-specific patterns of occupancy and abundance resulted in assemblage-level differences consistent with theoretical predictions for highly aquatic organisms along riparian gradients.
To assess antimicrobial prescriber knowledge, attitudes, and practices (KAP) regarding antimicrobial stewardship (AS) and associated barriers to optimal prescribing.
DESIGN
Cross-sectional survey.
SETTING
Online survey.
PARTICIPANTS
A convenience sample of 2,900 US antimicrobial prescribers at 5 acute-care hospitals within a hospital network.
INTERVENTION
The following characteristics were assessed with an anonymous, online survey in February 2015: attitudes and practices related to antimicrobial resistance, AS programs, and institutional AS resources; antimicrobial prescribing and AS knowledge; and practices and confidence related to antimicrobial prescribing.
RESULTS
In total, 402 respondents completed the survey. Knowledge gaps were identified through case-based questions. Some respondents sometimes selected overly broad therapy for the susceptibilities given (29%) and some “usually” or “always” preferred using the most broad-spectrum empiric antimicrobials possible (32%). Nearly all (99%) reported reviewing antimicrobial appropriateness at 48–72 hours, but only 55% reported “always” doing so. Furthermore, 45% of respondents felt that they had not received adequate training regarding antimicrobial prescribing. Some respondents lacked confidence selecting empiric therapy using antibiograms (30%), interpreting susceptibility results (24%), de-escalating therapy (18%), and determining duration of therapy (31%). Postprescription review and feedback (PPRF) was the most commonly cited AS intervention (79%) with potential to improve patient care.
CONCLUSIONS
Barriers to appropriate antimicrobial selection and de-escalation of antimicrobial therapy were identified among front-line prescribers in acute-care hospitals. Prescribers desired more AS-related education and identified PPRF as the most helpful AS intervention to improve patient care. Educational interventions should be preceded by and tailored to local assessment of educational needs.
The epidemiology of multiple sclerosis (MS) and the planning and interpretation of clinical therapeutic trials were the subjects of a symposium on MS held on June 13, 1989. Several speakers addressed whether MS is a genetic or an environmental disease. An environmental trigger would resolve the relatively low penetrance of the disease in susceptible individuals, although the alternative hypothesis that MS is a multigenic disease would also account for this observation. Clinical trials have to date failed to confirm the efficacy of any immunosuppressive or other agent in the management of progressive MS. Magnetic resonance imaging (MRI) appears to be highly sensitive for monitoring the activity of MS. Preliminary evidence suggests that MRI activity correlates with longitudinal clinical assessments of disability. Immunologic tests, while valuable in determining pathophysiology of MS, have not been strongly correlated with clinical outcome.
In this highly accessible introduction, Brian Nelson provides an overview of French literature - its themes and forms, traditions and transformations - from the Middle Ages to the present. Major writers, including Francophone authors writing from areas other than France, are discussed chronologically in the context of their times, to provide a sense of the development of the French literary tradition and the strengths of some of the most influential writers within it. Nelson offers close readings of exemplary passages from key works, presented in English translation and with the original French. The exploration of the work of important writers, including Villon, Racine, Molière, Voltaire, Balzac, Flaubert, Zola, Proust, Sartre and Beckett, highlights the richness and diversity of French literature.
From the point of view of pure Art, you could almost establish it as an axiom that the subject is irrelevant, style itself being an absolute way of seeing things.
– Flaubert, Letter to Louise Colet, 16 Jan. 1852
Gustave Flaubert (1821–80) was as influential in the field of fiction as Baudelaire was in poetry. His role in the evolution of the French novel is a subversive one. By shifting the novelist's emphasis from representation to composition, he began to undo the realist novel from within. His two great novels of contemporary life, Madame Bovary (1857) and Sentimental Education (L'Éducation sentimentale, 1869) adhere to a realist framework. They focus on mundane, antiheroic characters and contain an abundance of seemingly objective descriptions of settings and social milieus. What distinguishes Flaubert from Balzac and the ‘realist’ novelists of his own generation are his stylistic innovations and his self-consciousness as a writer. It is these aspects of his work that situate him on the dividing line between realism and the experimental writing of modernism, and account for his reputation as the creator of the ‘modern’ self-reflexive novel.
‘What I would like to write,’ Flaubert declared with provocative hyperbole, ‘is a book about nothing, a book dependent on nothing external, which would be held together by the inner strength of its style’ (letter to Louise Colet, 16 Jan. 1852). This statement indicates his ambition to give narrative prose the autonomy of stylization and the expressive qualities of poetry, and thereby to establish the novel as the dominant literary form of the nineteenth century. His narrative method has been called ‘impersonal’, by which is meant a kind of self suppression by the author – an implicit repudiation of the Romantic notions of creative inspiration and intense self-expression. For Flaubert, the presence of the writer in his work should remain elusive. Whereas the narrator of a Balzac novel is overtly (and often ostentatiously) omniscient, Flaubert's stated ideal was a different kind of God-like narrator, one who would be ‘present everywhere but visible nowhere’ (9 Dec. 1852).
The literary precursors of Surrealism include the Marquis de Sade (1740–1814), Victor Hugo (1802–85), Gérard de Nerval (1808–55), Charles Baudelaire (1821–67), the Comte de Lautréamont (1846–70), Arthur Rimbaud (1854–91), Alfred Jarry (1873–1907) and Guillaume Apollinaire (1880–1918). The social origins of the movement lay, first and foremost, in the French experience of the First World War (1914–18). The cataclysm of the ‘Great War’ made the values and culture of the nineteenth century, with its proud belief in progress and reason, God and patriotism, seem meaningless. The very concept of ‘civilization’ was thrown into question; civilization was a sham, and this meant that art could no longer be a celebration of it. The disillusion of the younger generation of artists and intellectuals was reflected in the aggressive antiart antics of the literary movement known as Dada or Dadaism (see above, p. 176). The aim of the Dadaists was to expose the culture of the past for the nonsense the war had proved it to be. The Dadaists' leader, the Romanian poet Tristan Tzara (1896–1963), chopped up newspaper articles, pasted them in random order and called them poems. When he arrived in Paris in 1919, he was warmly welcomed by a group of young poets: André Breton (1896–1966), Louis Aragon (1897–1982), Philippe Soupault (1897–1990), Robert Desnos (1900–45), Paul éluard (1895–1952) and others. These young men, some of whom had served in the war, rejected outright the civilization that seemed to have betrayed them. Within a few years Dada had burnt itself out, but its spirit of shock and provocation carried over into the more positive concept of avant-garde art which was to become Surrealism (the word was borrowed from Apollinaire, who coined it in his 1917 programme note for the ballet Parade). Surrealism was arguably the most influential avant-garde movement of the twentieth century, international in scope and extending to every form of artistic practice from poetry and prose narrative to painting, photography, film and theatre.
Molière (1622–73) is universally recognized as France's greatest comic playwright. He was also, by all accounts, the finest comic actor of his generation. He himself performed the leading roles in his plays, and at the same time was a director and manager: a complete man of the theatre. To focus on his plays as written texts, and to ignore questions of performance and stagecraft, would obscure our appreciation of his dramatic virtuosity, his specifically theatrical achievements and the remarkable variety of his work. Moreover, he was a highly self-conscious artist whose work constitutes a reflection, in the context of his times, on the nature and possibilities of comic drama. His achievement, as writer-actor-manager, was to renew comic drama in France and to give it something of the status of tragedy.
Comedy high and low
Born Jean-Baptiste Poquelin, in Paris, Molière enjoyed a comfortable bourgeois upbringing. His father was a prosperous tapissier (upholsterer and tapestryweaver) attached to the court of Louis XIII. He could have pursued a profitable career in his father's trade or in the law; however, he chose to abandon his studies in 1643 to become an actor, and this at a time when actors were often categorized on official documents with prostitutes and highwaymen and the Church taught that theatres were places of perdition. With Joseph and Madeleine Béjart, among others, Molière founded the Illustre Théâatre. But it went bankrupt in under two years, and the troupe was obliged to leave Paris. They toured the provinces for the next thirteen years, providing private performances for wealthy noblemen in their chateaux and public performances in the towns of southern France. It was during this period that Molière received the theatrical training that provided him with the basis for his later success in Paris.
… no society can complain of its intellectuals without accusing itself, for it has the intellectuals it makes.
– Sartre, ‘A Plea for Intellectuals’
When Jean-Paul Sartre (1905–1980) was arrested in 1970 for distributing seditious political literature in the streets of Paris, President de Gaulle vetoed the move to hold him in prison, reportedly saying: ‘You don't put Voltaire in prison.’ What he was alluding to by his comparison was that both men made themselves the radical consciences of their respective societies. Sartre – at once a philosopher, novelist, dramatist, literary critic, art critic, political theorist, political essayist and political activist – was as versatile and prolific as Voltaire, but more original. He dominated the intellectual life of the mid-twentieth century. He was the public intellectual par excellence.
Early years
The essential theme of Sartre's life and work is liberty. As a child, his rejection of authority was expressed in his rejection of his tyrannical grandfather, Charles Schweitzer, who ran a German school in Paris. He chose to become a writer precisely because his grandfather solemnly warned him against it. Sartre's brilliant account of his childhood, and of his relationship to culture and language, in Words (Les Mots, 1964) sheds much light on his later development. Sartre's father died when his son was fifteen months old, and Sartre and his mother were reintegrated into his grandfather's household, where they were both called ‘the children’ and brought up together almost as brother and sister. In Words he lays bare the forces that worked upon his consciousness a child, especially the bourgeois ideology embodied in his grandfather. The book is the judgement of the man on the child, but it is even more a judgement on a society that bred extreme forms of self-deception. Sartre presents himself as a young boy constrained to fit into an old-fashioned household and describes how he was constantly acting a part to please a dictatorial old man. At the heart of Sartre's work generally is a preoccupation with all forms of hypocrisy; playing roles, pretending to be someone or something one is not, came to represent a major crime in his eyes.
French literature of the Middle Ages is enormously rich and varied. It comprises, among other genres, heroic epics, courtly romances, verse narratives, religious drama, fables and lyric poetry. In recent years study of medieval French literature has been revitalized by innovative critical approaches that encourage the reading of relevant texts in terms of a literary culture built on sophisticated (and often playful) rewriting of traditional stories. Such approaches imply a fluid notion of literary creation untrammelled by restrictive notions of ‘author’ and ‘text’: ‘Medieval writers acknowledge that texts do not derive exclusively from or belong to their authors, that they have multiple origins, that they are indeed “a tissue of quotations” and, above all, that they go on developing and evolving as they are read, reread and rewritten in transmission.’ The lyric poet François Villon (c. 1431 – after 1463) recasts the courtly ideals and conventional pieties of medieval literary tradition, subverting his models by writing in a predominantly ironic mode. Lyric poetry and first-person narratives before Villon are strongly allegorical, and rarely the expression of individualized sentiment; lacking a clear historical dimension, they deal in stock character types (such as the knight-errant, despairing lover, repentant sinner, etc.) and are written in highly stylized poetic language. The greatest impact of Villon's work, as David Georgi argues, is its contribution to the emergence of the intimate first-person voice in European poetry. Villon also created, in his life and work, the figure of the poète maudit (the accursed poet, or poet with endless bad luck), who would become a familiar feature of the French poetic tradition. The poetic persona he developed evokes the experience of a marginal man living in a recognizable social reality: he engages imaginatively with the great themes of the literature and art of his age – death, the vagaries of fate, the ravages of time – in conjunction with poverty and the fragility of existence in fifteenth-century Paris.
I have an obsession with authentic detail; the springboard of precise observation makes possible the leap into the stars.
– Zola, Letter to Henry Céard, 22 March 1885
Unlike Flaubert, the ‘hermit of Croisset’, who turned away from his age in an attitude of ironic detachment, Émile Zola (1840–1902) embraced his century in away no French writer had done since Balzac. Zola's ambition was to emulate Balzac by writing a comprehensive history of contemporary society. His main achievement was his twenty-volume novel cycle, Les Rougon-Macquart, published between 1871 and 1893. The fortunes of a family, the Rougon-Macquart, are followed over several decades. The various family members spread throughout all levels of society, and through their lives Zola examines methodically the social, sexual and moral landscape of the late nineteenth century. Zola is the quintessential novelist of modernity, understood as a time of tumultuous change. The motor of change was the rapid expansion of capitalism, with all that that entailed in terms of the altered shapes of the city, new forms of social practice and economic organization, and heightened political pressures. Zola was fascinated by change, and specifically by the emergence of a new, mass society.
Zola rejected much of the social and moral content of the bourgeois worldview, but he retained the central epistemological tenet on which it was based: ‘scientific’ objectivity. Converted from a youthful romantic idealism to realism in art and literature, he began promoting a scientific view of literature inspired by the aims and methods of experimental medicine. He called this new form of realism ‘naturalism’. The subtitle of the Rougon-Macquart cycle, ‘A Natural and Social History of a Family under the Second Empire’, suggests Zola's two interconnected aims: to use fiction to demonstrate a number of ‘scientific’ notions about the ways in which human behaviour is determined by heredity and environment; and to use the symbolic possibilities of a family whose heredity is tainted to represent a diseased society – the corrupt yet dynamic France of the Second Empire (1852–70).
– Rimbaud, Letter to Georges Izambard, 13 May 1871
Arthur Rimbaud (1854–91) was one of the most challenging and liberating influences on modern French culture – always on the move in his life and in his writing, always on his way to somewhere else, assuming and casting off identities as he went. There was the child prodigy, at fifteen writing poetry that showed a complete mastery of French classical forms and prosody, combined with a stunningly original style. There was the teenage rebel, the filthy, foul-mouthed peasant boy, repudiating family and religion, turning up in Paris and scandalizing the literary establishment with his iconoclastic views on poetry and his amazingly anti-social behaviour. There was the relationship with Verlaine and the vagabond years spent with the older poet in Paris, London and Brussels. Meanwhile, by the age of twenty, Rimbaud had composed a body of work that is widely considered one of the most innovative and significant of the French nineteenth century.
The poet as seer
Rimbaud's early years were spent on a farm at Roche, near the Belgian border, and then in the small nearby town of Charleville. He was brought up by his mother – his father, an army officer, having left her when Rimbaud was six. Vitalie Rimbaud, with her peasant avarice, grim piety, social ambition and iron discipline, cast a long shadow over her son's life. Ironically, Rimbaud got from his mother the toughness and determination he needed to escape from her and from everything she represented for him. He ran away to Paris when he was fifteen. His first views of the city were through the grill in the back of a police wagon, for he was arrested on arrival at the railway station for travelling without a ticket. After a few days, he was released, and made his way circuitously back home. He returned to Paris a few months later, this time with a ticket. Back in Charleville, he was greatly excited when Paris declared itself an independent people's republic, and in the spring of 1871 he decided to return to the capital to witness the dawn of the new age.