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Dropout from healthcare interventions can negatively affect patients and healthcare providers through impaired trust in the healthcare system and ineffective use of resources. Research on this topic is still largely missing on refugees and asylum seekers. The current study aimed to characterize predictors for dropout in the Mental Health in Refugees and Asylum Seekers (MEHIRA) study, one of the largest multicentered controlled trials investigating the effectiveness and cost-effectiveness of a nationwide stepped and collaborative care model.
Methods
Predictors were multiply imputed and selected for descriptive modelling using backward elimination. The final variable set was entered into logistic regression.
Results
The overall dropout rate was 41,7%. Dropout was higher in participants in group therapy (p = 0.001; OR = 10.7), with larger satisfaction with social relationships (p = 0.017; OR = 1.87), with difficulties in maintaining personal relationships (p = 0.005; OR = 4.27), and with higher depressive symptoms (p = 0.029; OR = 1.05). Participants living in refugee accommodation (p = 0.040; OR = 0.45), with a change in social status (p = 0.008; OR = 0.67) and with conduct (p = 0.020; OR = 0.24) and emotional problems (p = 0.013; OR = 0.31) were significantly less likely to drop out of treatment.
Conclusion
Overall, the outcomes of this study suggest that predictors assessing social relationships, social status, and living conditions should be considered as topics of psychological treatment to increase adherence and as predictors for future research studies (including treatment type).
Refugees and asylum seekers (RAS) in Germany need tailored and resource-oriented mental healthcare interventions.
Aims
To evaluate the cost-effectiveness of group psychotherapy for RAS with moderate depressive symptoms.
Method
This is a post hoc cost-effectiveness analysis of Empowerment group psychotherapy that was embedded in a stratified stepped and collaborative care model (SCCM) from the multicentre randomised controlled MEHIRA trial. One hundred and forty-nine participants were randomly assigned to SCCM or treatment as usual (TAU) and underwent Empowerment (i.e. level 3 of the SCCM for adults) or TAU. Effects were measured with the nine-item Patient Health Questionnaire (PHQ-9) and quality adjusted life-years (QALY) post-intervention. Health service and intervention costs were measured. Incremental cost-effectiveness ratios (ICER) were estimated and net monetary benefit (NMB) regressions with 95% confidence intervals were performed. Cost-effectiveness was ascertained for different values of willingness to pay (WTP) using cost-effectiveness acceptability curves for probable scenarios. Trial registration number: NCT03109028 on ClinicalTrials.gov.
Results
Health service use costs were significantly lower for Empowerment than TAU after 1 year. Intervention costs were on average €409.6. Empowerment led to a significant change in PHQ-9 scores but not QALY. Bootstrapped mean ICER indicated cost-effectiveness according to PHQ-9 and varied considerably for QALY in the base case. NMB for a unit reduction in PHQ-9 score at WTP of €0 was €354.3 (€978.5 to −€269.9). Results were confirmed for different scenarios and varying WTP thresholds.
Conclusions
The Empowerment intervention was cost-effective in refugees with moderate depressive symptoms regarding the clinical outcome and led to a reduction in direct healthcare consumption. Concerning QALYs, there was a lack of confidence that Empowerment differed from TAU.
European Criminal Law has developed into a complex, jagged subject matter, which at the same time has become increasingly important for everyday criminal law practice. On the one hand, this work aims to do comprehensive justice to the complexity of the matter without sacrificing readability. In order to achieve this, the book’s structure enables legal scholars and experienced practitioners to access the information relevant to them in a targeted manner and, at the same time, enables less-oriented readers to gain access to European Criminal Law. Thus, the volume both answers basic questions and offers discussion in more specialised areas. Written by experts in the field, the book offers discussions that are both of the highest academic standards and accessibly readable.
In this work, we focus on a multi-hole pressure-probe-based flow measurement system for wind tunnel measurements that provides real-time feedback to a robot probe-manipulator, rendering the system autonomous. The system relies on a novel, computationally efficient flow analysis technique that translates the probe's point measurements of velocity and pressure into an updatable mean flow map that is accompanied by an uncertainty metric. The latter provides guidance to the manipulator when planning the optimal probe path. The probe is then guided by the robot in the flow domain until an available time budget has been exhausted, or until the uncertainty metric falls below a prescribed target threshold in the entire flow domain. We assess the capabilities of our new measurement system using computational fluid dynamics data, for which the ground truth is available in the form of a mean flow field. An application in a real wind tunnel setting is provided as well.
Disruptive behavior disorders (DBD) are heterogeneous at the clinical and the biological level. Therefore, the aims were to dissect the heterogeneous neurodevelopmental deviations of the affective brain circuitry and provide an integration of these differences across modalities.
Methods
We combined two novel approaches. First, normative modeling to map deviations from the typical age-related pattern at the level of the individual of (i) activity during emotion matching and (ii) of anatomical images derived from DBD cases (n = 77) and controls (n = 52) aged 8–18 years from the EU-funded Aggressotype and MATRICS consortia. Second, linked independent component analysis to integrate subject-specific deviations from both modalities.
Results
While cases exhibited on average a higher activity than would be expected for their age during face processing in regions such as the amygdala when compared to controls these positive deviations were widespread at the individual level. A multimodal integration of all functional and anatomical deviations explained 23% of the variance in the clinical DBD phenotype. Most notably, the top marker, encompassing the default mode network (DMN) and subcortical regions such as the amygdala and the striatum, was related to aggression across the whole sample.
Conclusions
Overall increased age-related deviations in the amygdala in DBD suggest a maturational delay, which has to be further validated in future studies. Further, the integration of individual deviation patterns from multiple imaging modalities allowed to dissect some of the heterogeneity of DBD and identified the DMN, the striatum and the amygdala as neural signatures that were associated with aggression.
How do criminal lawyers sequence and give shape to their reasoning about criminal liability? Why do they ‘structure’ it as they do? This chapter looks at structure within legal reasoning as a means of understanding the law in the minds of criminal lawyers. It seeks to better understand how structures function and interact. One benefit of doing so is to help lawyers foreign to the legal systems analyse liability as a native might. Another benefit is that, by looking at two paradigmatic orchestrations of the many substantive, organisational and practical issues within criminal legal reasoning, the interconnectedness, priority and valuing of those elements can be revealed and made comparable.
Alcohol use disorder (AUD) and schizophrenia (SCZ) frequently co-occur, and large-scale genome-wide association studies (GWAS) have identified significant genetic correlations between these disorders.
Methods
We used the largest published GWAS for AUD (total cases = 77 822) and SCZ (total cases = 46 827) to identify genetic variants that influence both disorders (with either the same or opposite direction of effect) and those that are disorder specific.
Results
We identified 55 independent genome-wide significant single nucleotide polymorphisms with the same direction of effect on AUD and SCZ, 8 with robust effects in opposite directions, and 98 with disorder-specific effects. We also found evidence for 12 genes whose pleiotropic associations with AUD and SCZ are consistent with mediation via gene expression in the prefrontal cortex. The genetic covariance between AUD and SCZ was concentrated in genomic regions functional in brain tissues (p = 0.001).
Conclusions
Our findings provide further evidence that SCZ shares meaningful genetic overlap with AUD.
Lawyers have drawn on the distinction between crime and tort for a long time and in various contexts. There exist today many different criteria which supposedly circumscribe and demarcate the domains of crime and tort. English scholars, for instance, refer to several indicia such as:
1. moral or natural description of the wrong;
2. characterisation of the process of remedying the wrong as being of public concern rather than merely private;
3. the presence of measures that are typically perceived as quintessential forms of criminal sanctions (‘penalty’) or compensation;
4. a positivist approach of some kind, focusing on the process of creating the legal classifications and thus their resulting form;
5. a procedural approach, focusing on which court or what other legal actor deals with the issue.
Similar elements and characterisations can be found in the German discussion. Tort is primarily associated with the compensation of present and the prevention of future damage, whereas crime authorises state punishment the ultimate purpose of which could vary and has done so over time. German scholars emphasise that it is the stigmatising effect of public condemnation (sozialethisches Unwerturteil) inherent in criminal convictions that sets the field of crime apart from any other form of public sanction. However, since very few forms of punishment have come to be regarded as quintessentially criminal – imprisonment, most notably – it has basically fallen to the legislature to create criminal sanctions which can be imposed as part of a criminal conviction. Other definitional elements such as imposition by a criminal court or tying its legitimacy to infringements of fundamental social norms can also be found in German publications on the nature of crime. German scholars have conceived of the so-called Rechtsgutstheorie (theory of protected legal interests) in order to delimit the legitimate scope of deviations from social norms that deserve punishment. Although it has not been recognised as a constitutional concept under the German Basic Law (Grundgesetz), the theory still finds widespread support among academics. The protection of (positively recognised) legal interests also lies at the heart of the law of delict. But the idea of Rechtsgüterschutz is, at least in theory, a much richer concept claiming to guide and constrain legislative powers, whereas delictual liability builds on positive private law provisions and rights and thus does not have a similarly critical nature.
Pathological gambling is a behavioural addiction with negative economic, social, and psychological consequences. Identification of contributing genes and pathways may improve understanding of aetiology and facilitate therapy and prevention. Here, we report the first genome-wide association study of pathological gambling. Our aims were to identify pathways involved in pathological gambling, and examine whether there is a genetic overlap between pathological gambling and alcohol dependence.
Methods
Four hundred and forty-five individuals with a diagnosis of pathological gambling according to the Diagnostic and Statistical Manual of Mental Disorders were recruited in Germany, and 986 controls were drawn from a German general population sample. A genome-wide association study of pathological gambling comprising single marker, gene-based, and pathway analyses, was performed. Polygenic risk scores were generated using data from a German genome-wide association study of alcohol dependence.
Results
No genome-wide significant association with pathological gambling was found for single markers or genes. Pathways for Huntington's disease (P-value = 6.63 × 10−3); 5′-adenosine monophosphate-activated protein kinase signalling (P-value = 9.57 × 10−3); and apoptosis (P-value = 1.75 × 10−2) were significant. Polygenic risk score analysis of the alcohol dependence dataset yielded a one-sided nominal significant P-value in subjects with pathological gambling, irrespective of comorbid alcohol dependence status.
Conclusions
The present results accord with previous quantitative formal genetic studies which showed genetic overlap between non-substance- and substance-related addictions. Furthermore, pathway analysis suggests shared pathology between Huntington's disease and pathological gambling. This finding is consistent with previous imaging studies.
Late Quaternary landscapes of unglaciated Beringia were largely shaped by ice-wedge polygon tundra. Ice Complex (IC) strata preserve such ancient polygon formations. Here we report on the Yukagir IC from Bol'shoy Lyakhovsky Island in northeastern Siberia and suggest that new radioisotope disequilibria (230Th/U) dates of the Yukagir IC peat confirm its formation during the Marine Oxygen Isotope Stage (MIS) 7a–c interglacial period. The preservation of the ice-rich Yukagir IC proves its resilience to last interglacial and late glacial–Holocene warming. This study compares the Yukagir IC to IC strata of MIS 5, MIS 3, and MIS 2 ages exposed on Bol'shoy Lyakhovsky Island. Besides high intrasedimental ice content and syngenetic ice wedges intersecting silts, sandy silts, the Yukagir IC is characterized by high organic matter (OM) accumulation and low OM decomposition of a distinctive Drepanocladus moss-peat. The Yukagir IC pollen data reveal grass-shrub-moss tundra indicating rather wet summer conditions similar to modern ones. The stable isotope composition of Yukagir IC wedge ice is similar to those of the MIS 5 and MIS 3 ICs pointing to similar atmospheric moisture generation and transport patterns in winter. IC data from glacial and interglacial periods provide insights into permafrost and climate dynamics since about 200 ka.
The European Project for Ice Coring in Antarctica (EPICA) focuses on the drilling of two deep ice cores, the first at Dome C and the second at Kohnen station (75°00’ S, 0°04’ E) in Dronning Maud Land (DML). This paper deals with stable-isotope records from ice cores drilled in DML. In the first season, the deep EPICA DML core reached a depth of 450 m, recovering ice approximately 7000 years old. Generally, the δ18O record indicates a stable Holocene climate and shows low variability. However, during the last 4000 years (based on a preliminary time-scale) the δ18O values decrease continuously by about 0.6%, and the deuterium excess values increase by about 0.5%. The correlation between δ18O and the deuterium excess d is investigated for a 50m long core section and the near-surface snow. High-pass filtered profiles are positively correlated, whereas the correlation between low-pass filtered profiles is negative. A post-depositional effect due to diffusion processes can be seen in a sub-annually resolved profile from snow-pit samples. Changes in the seasonality of the evolution of the snow cover and the consequences for stable-isotope content are demonstrated with data from ice core B31.
The paper presents first results from the upper 54m of a 723.91m ice core drilled on Akademii Nauk ice cap, Severnaya Zemlya, Eurasian Arctic, in 1999– 2001, supplemented by data from shallow ice cores. the glacier’s peculiarity is the infiltration and refreezing of meltwater, which changes the original isotopic and chemical signals. Therefore, stratigraphical observations in these ice cores are more difficult than in those from central Greenland or Antarctica. However, the 1963 maximum of artificial radioactivity from atmospheric nuclear tests is clearly detectable in the deep ice core, and the δ18O profile of a 12.82 m shallow core shows annual variations. Consequently, at least for the upper part of the main core, an almost seasonal time resolution of palaeoclimate record could be expected. the Chernobyl layer is detected by increased 137Cs activity at depths of 11.81–12.51m related to the AD 2000 surface. the resulting mean annual net mass balance is 53±2 g cm–2 a–1. Data from dielectric profiling of the main core show considerable peaks in conductivity; one of them is interpreted as a volcano event. According to the resulting chronology, this part of the core represents approximately the last 100 years.
Between 1999 and 2001, a 724 m long ice core was drilled on Akademii Nauk, the largest glacier on Severnaya Zemlya, Russian Arctic. The drilling site is located near the summit. The core is characterized by high melt-layer content. The melt layers are caused by melting and even by rain during the summer. We present high-resolution data of density, electrical conductivity (dielectrical profiling), stable water isotopes and melt-layer content for the upper 136m (120 m w.e.) of the ice core. The dating by isotopic cycles and electrical conductivity peak identification suggests that this core section covers approximately the past 275 years. Singularities of volcanogenic and anthropogenic origin provide well-defined additional time markers. Long-term temperatures inferred from 12 year running mean averages of δ18O reach their lowest level in the entire record around 1790. Thereafter the δ18O values indicate a continuously increasing mean temperature on the Akademii Nauk ice cap until 1935, interrupted only by minor cooling episodes. The 20th century is found to be the warmest period in this record.
Four firn cores were retrieved in 2007 at two ridges in the area of the Ekström Ice Shelf, Dronning Maud Land, coastal East Antarctica, in order to investigate the recent regional climate variability and the potential for future extraction of an intermediate-depth core. Stable water-isotope analysis, tritium content and electrical conductivity were used to date the cores. For the period 1981–2006 a strong and significant correlation between the stable-isotope composition of firn cores in the hinterland and mean monthly air temperatures at Neumayer station was (r = 0.54−0.71). No atmospheric warming or cooling trend is inferred from our stable-isotope data for the period 1962–2006. The stable-isotope record of the ice/firn cores could expand well beyond the meteorological record of the region. No significant temporal variation of accumulation rates was detected. However, decreasing accumulation rates were found from coast to hinterland, as well as from east (Halvfarryggen) to west (Søråsen). The deuterium excess (d) exhibits similar differences (higher d at Søråsen, lower d at Halvfarryggen), with a weak negative temporal trend on Halvfarryggen (0.04‰ a−1), probably implying increasing oceanic input. We conclude that Halvfarryggen acts as a natural barrier for moisture-carrying air masses circulating in the region from east to west.
From 1999 to 2001 a 724 m deep ice core was drilled on Akademii Nauk ice cap, Severnaya Zemlya, to gain high-resolution proxy data from the central Russian Arctic. Despite strong summertime meltwater percolation, this ice core provides valuable information on the regional climate and environmental history. We present data of stable water isotopes, melt-layer content and major ions from the uppermost 57 m of this core, covering the period 1883–1998. Dating was achieved by counting seasonal isotopic cycles and using reference horizons. Multi-annual δ18O values reflect Eurasian sub-Arctic and Arctic surface air-temperature variations. We found strong correlations to instrumental temperature data from some stations (e.g. r = 0.62 for Vardø, northern Norway). The δ18O values show pronounced 20th-century temperature changes, with a strong rise about 1920 and the absolute temperature maximum in the 1930s. A recent decrease in the deuterium-excess time series indicates an increasing role of the Kara Sea as a regional moisture source. From the multi-annual ion variations we deduced decreasing sea-salt aerosol trends in the 20th century, as reflected by sodium and chloride, whereas sulphate and nitrate are strongly affected by anthropogenic pollution.
The government publishes 3 different public report surgical site infection (SSI) metrics, all called standardized infection ratios (SIRs), that impact perceived hospital quality. We conducted a non-random cross-sectional observational pilot study of 20 California hospitals that voluntarily submitted colon surgery and SSI data. Discordant SIR values, leading to contradictory conclusions, occurred in 35% of these hospitals.
A consensus conference on the reasons for the undertreatment of depression was organized by the National Depressive and Manic Depressive Association (NDMDA) on January 17–18,1996. The target audience included health policymakers, clinicians, patients and their families, and the public at large. Six key questions were addressed: (1) Is depression undertreated in the community and in the clinic? (2) What is the economic cost to society of depression? (3) What have been the efforts in the past to redress undertreatment and how successful have they been? (4) What are the reasons for the gap between our knowledge of the diagnosis and treatment of depression and actual treatment received in this country? (5) What can we do to narrow this gap? (6) What can we do immediately to narrow this gap?