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Principles of Medicine in Africa combines clinical medicine with a rich understanding of the major environmental and cultural influences on health and disease, providing comprehensive guidance for anyone intending to practise medicine in Africa. Presenting disease in the context of family and culture, the effects of inequality and problems of limited resources are addressed. The authors have a wealth of experience in front line healthcare in Africa and provide practical, evidence-based management guidelines for all the common and less common conditions likely to be encountered. This fifth edition has been thoroughly updated to incorporate the latest research findings and management guidelines and there has been much greater involvement of African physicians in the writing and editorial process. The chapters on cancer and non-communicable diseases have been expanded and new chapters have been added on digital health, critical care in a resource-limited setting, antimicrobial resistance, COVID-19 and other emerging infectious diseases.
Physical health checks in primary care for people with severe mental illness ((SMI) defined as schizophrenia, bipolar disorders and non-organic psychosis) aim to reduce health inequalities. Patients who decline or are deemed unsuitable for screening are removed from the denominator used to calculate incentivisation, termed exception reporting.
Aims
To describe the prevalence of, and patient characteristics associated with, exception reporting in patients with SMI.
Method
We identified adult patients with SMI from the UK Clinical Practice Research Datalink (CPRD), registered with a general practice between 2004 and 2018. We calculated the annual prevalence of exception reporting and investigated patient characteristics associated with exception reporting, using logistic regression.
Results
Of 193 850 patients with SMI, 27.7% were exception reported from physical health checks at least once. Exception reporting owing to non-response or declining screening increased over the study period. Patients of Asian or Black ethnicity (Asian: odds ratio 0.72, 95% CI 0.65–0.80; Black: odds ratio 0.86, 95% CI 0.76–0.97; compared with White) and women (odds ratio 0.90, 95% CI 0.88–0.92) had a reduced odds of being exception reported, whereas patients diagnosed with ‘other psychoses’ (odds ratio 1.19, 95% CI 1.15–1.23; compared with bipolar disorder) had increased odds. Younger patients and those diagnosed with schizophrenia were more likely to be exception reported owing to informed dissent.
Conclusions
Exception reporting was common in people with SMI. Interventions are required to improve accessibility and uptake of physical health checks to improve physical health in people with SMI.
People with severe mental illness (SMI) have a higher risk of premature mortality than the general population.
Aims
To investigate whether the life expectancy gap for people with SMI is widening, by determining time trends in excess life-years lost.
Method
This population-based study included people with SMI (schizophrenia, bipolar disorder and major depression) alive on 1 January 2000. We ascertained SMI from psychiatric hospital admission records (1981–2019), and deaths via linkage to the national death register (2000–2019). We used the Life Years Lost (LYL) method to estimate LYL by SMI and sex, compared LYL to the Scottish population and assessed trends over 18 3-year rolling periods.
Results
We included 28 797 people with schizophrenia, 16 657 with bipolar disorder and 72 504 with major depression. Between 2000 and 2019, life expectancy increased in the Scottish population but the gap widened for people with schizophrenia. For 2000–2002, men and women with schizophrenia lost an excess 9.4 (95% CI 8.5–10.3) and 8.2 (95% CI 7.4–9.0) life-years, respectively, compared with the general population. In 2017–2019, this increased to 11.8 (95% CI 10.9–12.7) and 11.1 (95% CI 10.0–12.1). The life expectancy gap was lower for bipolar disorder and depression and unchanged over time.
Conclusions
The life expectancy gap in people with SMI persisted or widened from 2000 to 2019. Addressing this entrenched disparity requires equitable social, economic and health policies, healthcare re-structure and improved resourcing, and investment in interventions for primary and secondary prevention of SMI and associated comorbidities.
This article examines the intersection between forced labour, supply chain risks and environmental, social and governance concerns that pose a threat to the ‘Just Transition’. It addresses how states, businesses and other stakeholders drive or fail Just Transitions and why. Through an application of a ‘policy currents framework’ to the case study of solar panel supply chains originating in China, we analyse states, international organisations and civil society organisations’ framing of modern slavery issues in the context of the ‘Just Transition’. We focus on the framing of challenges and solutions to the nexus of forced labour and climate change. We draw attention to the fact decarbonisation risks are being achieved at the cost of labour rights abuses within supply chains, question whether the concept of renewable sources is ‘Just’ and provide a series of recommendations for stakeholders.
Genetic and environmental factors, including adverse childhood experiences (ACEs), contribute to substance use disorders (SUDs). However, the interactions between these factors are poorly understood.
Methods
We examined associations between SUD polygenic scores (PGSs), ACEs, and the initiation of use and severity of alcohol (AUD), opioid use disorder (OUD), and cannabis use disorder (CanUD) in 10,275 individuals (43.5% female, 47.2% African-like ancestry [AFR], and 52.8% European-like ancestry [EUR]). ACEs and SUD severity were modeled as latent factors. We conducted logistic and linear regressions within ancestry groups to examine the associations of ACEs, PGS, and their interaction with substance use initiation and SUD severity.
Results
All three SUD PGS were associated with ACEs in EUR individuals, indicating a gene–environment correlation. Among EUR individuals, only the CanUD PGS was associated with initiating use, whereas ACEs were associated with initiating use of all three substances in both ancestry groups. Additionally, a negative gene-by-environment interaction was identified for opioid initiation in EUR individuals. ACEs were associated with all three SUD severity latent factors in EUR individuals and with AUD and CanUD severity in AFR individuals. PGS were associated with AUD severity in both ancestry groups and with CanUD severity in AFR individuals. Gene-by-environment interactions were identified for AUD and CanUD severity among EUR individuals.
Conclusions
Findings highlight the roles of ACEs and polygenic risk in substance use initiation and SUD severity. Gene-by-environment interactions implicate ACEs as moderators of genetic susceptibility, reinforcing the importance of considering both genetic and environmental influences on SUD risk.
Film offers untapped potential for making critical interventions in world politics, particularly in ways that harness people’s capacity to narrate stories that creatively empower their communities. Combining International Relations scholarship on visual politics with narrative theory and feminist scholarship on care, this paper presents film as a means of exploring and expressing narrative agency; that is, the power to tell stories that represent people’s experiences in ways that disrupt hegemonic narratives. Dialectics of care and narrative agency are explored in the context of military-to-civilian ‘transition’ in Britain. We argue that the landscape of transition for military veterans is dominated by a preoccupation with employment and economic productivity, resulting in a ‘care deficit’ for veterans leaving the military. Through the Stories in Transition project, which used co-created film to explore narrative agency in the context of three veterans’ charities, we argue that the act of making care visible constitutes a necessary intervention in this transitional landscape. Grounding this intervention within feminist care ethics and the related notion of care aesthetics, we highlight the potential for film to reveal in compelling audio-visual narratives an alternative project of transition which might better sustain life and hope in the aftermath of military service.
A topic of recent interest involves the nature of theistic faith, and in particular, the boundaries of such faith. For example, philosophers have taken opposing positions on whether atheists and agnostics can have theistic faith. I consider a related question: whether anti-theists, who think God’s existence would be a bad thing, can have faith. I argue for a negative answer, although with several caveats.
Objectives/Goals: This study will integrate scientific evidence to create messaging about the modifiable risk factors for Alzheimer’s disease (AD) and examine how culturally tailoring elements in message content, such as text and visualizations in infographic messaging, impacts cognitive processing of AD prevention messages among Black adults. Methods/Study Population: This study is guided by the two-dimensional theory of cultural sensitivity and the elaboration likelihood model (ELM). The two-dimensional theory distinguishes between surface structure (visualizations) and deep structure (text with embedded cultural features) in messaging. The ELM considers how message attributes influence cognitive processing. A 2 × 2 factorial experiment will test the impact of cultural features (surface vs. deep) and message type (text-based vs. infographic) on persuasive outcomes regarding modifying AD risk factors. Black adults will be recruited from local churches and randomly assigned to one of four conditions, after which they will complete post-test measures. Statistical analyses will determine the effects of cultural tailoring and message effects on outcome variables. Results/Anticipated Results: Guided by previous literature (Resnicow et al., 1999; Lazard & Atkinson, 2015; Lam et al., 2022), we hypothesize an interaction effect of cultural tailoring and message type, wherein surface structure infographic messages and deep structure text-based messages will outperform the other two message conditions, resulting in greater cognitive processing and more positive attitudes and behavioral intentions toward modifying AD risk factors. In addition, a research question asks whether there will be differences between surface structure infographic messages and deep structure text-based messages on outcome variables. The study will advance understanding of the effects of cultural sensitivity and visual vs. text-based messaging by integrating these literatures. Discussion/Significance of Impact: This research will contribute to the literature on culturally tailored health messages and persuasive effects of text vs. visual messages. The findings can inform the development of more effective, culturally relevant public health campaigns for AD prevention by reducing risk for AD through modifiable risk factors in diverse populations.
We study the descriptive complexity of sets of points defined by restricting the statistical behaviour of their orbits in dynamical systems on Polish spaces. Particular examples of such sets are the sets of generic points of invariant Borel probability measures, but we also consider much more general sets (for example, $\alpha $-Birkhoff regular sets and the irregular set appearing in the multifractal analysis of ergodic averages of a continuous real-valued function). We show that many of these sets are Borel in general, and all these are Borel when we assume that our space is compact. We provide examples of these sets being non-Borel, properly placed at the first level of the projective hierarchy (they are complete analytic or co-analytic). This proves that the compactness assumption is, in some cases, necessary to obtain Borelness. When these sets are Borel, we measure their descriptive complexity using the Borel hierarchy. We show that the sets of interest are located at most at the third level of the hierarchy. We also use a modified version of the specification property to show that these sets are properly located at the third level of the hierarchy for many dynamical systems. To demonstrate that the specification property is a sufficient, but not necessary, condition for maximal descriptive complexity of a set of generic points, we provide an example of a compact minimal system with an invariant measure whose set of generic points is $\boldsymbol {\Pi }^0_3$-complete.
The ability of private law to shape health care and public health is evident in the effects that tort law had on improving patient safety in anesthesiology and curtailing the marketing of tobacco products. One would think of health care costs as a fertile area for litigation, for many reasons: widespread provider of opportunism that invites legal challenges under a number of theories; the considerable resources that payers and health policy philanthropies have available to invest in litigation strategies; and the high stakes involved in a large industry that is unusually aggressive in the chase for consumer and health insurance dollars. One can find numerous examples of parties pursuing legal action to lower costs, often successfully. But what is striking about these cases is how isolated they are – largely individual, uncoordinated efforts – and how they have failed to meaningfully curtail provider excesses. Most tellingly, the problem of balance billing by out-of-network physicians never gave rise to significant litigation and was resolved by Congressional action that, ironically, incorporated existing common law doctrines.
This paper reviews instances of provider opportunism to obtain higher prices, including contriving to bill “charges” rather than accepting market prices for services; “upcoding” for services by overstating the amount of work involved; and consolidation to achieve market concentration and power vis-a-vis payers. It then discusses available legal theories to remedy such conduct and inventories efforts to invoke them. Finally, it applies political science theories to analyze potential explanations for the dearth of litigation in this area.
This study explored the effects of different human milk oligosaccharides (HMOs), solely and in combination, on gut microbiota composition and metabolic activity (organic acid production), using anaerobic in vitro batch culture fermenters. The aim was to compare prebiotic effects of HMOs (2’FL, 3’FL, 3’SL, 6’SL, LNT, LNnT, and 1:1 ratio mixes of 2’FL/3’SL and 3’SL/LNT) in faecal samples from irritable bowel syndrome (IBS) donors and healthy controls, and to determine the best-performing HMO in IBS. Fluorescent in situ hybridisation coupled with flow cytometry was utilised to study microbiota changes in major colonic genera, and organic acid production was assessed by gas chromatography. IBS donors had different starting microbial profiles compared to healthy controls and lower levels of organic acids. In response to HMOs, there were alterations in both the control and IBS faecal microbiomes. In IBS donor fermenters, Bifidobacterium, Faecalibacterium, total bacterial numbers, and organic acid production significantly increased post-HMO intervention. When comparing the effect of HMO interventions on the microbiota and organic acid production, a mix of 3’SL/LNT HMOs may be the most promising intervention for IBS patients.
It is still an open question when groups perform better than individuals in intellective tasks. We report that in an Acquiring a Company game, what prevailed when there was disagreement among group members was the median proposal and not the best proposal. This aggregation rule explains why groups underperformed with respect to a “truth wins” benchmark and why they performed better than individuals deciding in isolation in a simple version of the task but worse in the more difficult version. Implications are drawn on when to employ groups rather than individuals in decision making.
This study aimed to assess Well-Being Index scores in paediatric cardiac ICU (PCICU) registered nurses and advanced practice providers. Secondary objectives included identifying factors correlating with at-risk Well-Being Index scores and exploring predictors of these scores, with attention to the impact of the coronavirus disease 2019 pandemic. A multicentre electronic survey was conducted between October 2021 and January 2022. Registered nurses and advanced practice providers working in PCICUs at US centres participating in the Collaborative Research from the Pediatric Cardiac Intensive Care Society were included.
The survey included the nine-item Well-Being Index and questions about demographics and factors influencing well-being, such as coronavirus disease 2019. The Well-Being Index is a validated tool to predict workforce distress and well-being. Out of 218 participants (180 registered nurses, 38 advanced practice providers), 137 registered nurses (76%) and 15 advanced practice providers (39%) had at-risk Well-Being Index scores. A total of 61% of nurses and 34% of advanced practice providers reported an intent to leave. Intent to leave was significantly linked to lower well-being for registered nurses (p = 0.002). Leadership support reduced registered nurses’ distress risk by 68% compared to no support (p = 0.04). Increased stress since coronavirus disease 2019 raised registered nurses’ poor well-being risk by four times (p = 0.001). PCICU registered nurses and advanced practice providers are at risk for poor well-being, exacerbated by the pandemic. Those with poor well-being may be more likely to leave. Leadership support is vital for nurses’ well-being. Further research is needed to establish baseline well-being.
Of 313 patients whose outpatient parenteral antimicrobial therapy was managed by an ID physician, only 39 [12.5%, 95% CI (8.8%–16.1%)] had clinical decisions influenced by erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), or both. ESR/CRP ordering was associated with $530 in excess cost per treatment course (average duration 5.1 weeks) representing a diagnostic stewardship opportunity.
Joseph Addison’s Cato (1713) is a play in the US-American bloodstream: it was quoted repeatedly by the architects of the American Revolution and was famously performed by Washington’s troops at Valley Forge in 1778. But what does this 300-year-old verse tragedy—with its entangled political, racial, and theatrical histories and implications—have to say to audiences in the present-day US South at the Clarence Brown Theatre, Tennessee, in 2023?
We present the first nonlinear results on the problem of non-rotating thermal convection in an internally heated full sphere. A nonlinear stability analysis by the energy method yields that, at least for no-slip boundary conditions, the critical Rayleigh numbers for linear stability and nonlinear stability coincide. We then explore different ranges of the parameter regime using direct numerical simulations. We first report on the system behaviour for a fixed Prandtl number of unity and both stress-free and no-slip boundary conditions up to very high forcing, reaching Rayleigh number $Ra=2\times 10^{12}$, approximately 250 million times the critical value ($Ra_c$) for the onset of convection under no-slip conditions. For both boundary conditions, we observe a scaling for the advective heat transfer measured by the Nusselt number $Nu$ close to $Nu \sim Ra^{1/4}$. This is consistent with a scaling prediction that we formulate analogously to the classical scaling in Rayleigh–Bénard convection. We then investigate the Prandtl number dependence at low to intermediate forcing for stress-free boundary conditions in the ranges $0.1 \leq Pr \leq 30$ and $Ra_c=3091\leq Ra \leq 3\times 10^5 \approx 100Ra_c$. We find five distinct dynamical regimes depending on the Prandtl number, describe each regime individually and issue heuristic interpretations of the system behaviour where possible.
In 2003, Ozsváth, Szabó and Rasmussen introduced the $\tau $ invariant for knots, and in 2011, Sarkar [‘Grid diagrams and the Ozsváth–Szabó tau-invariant’, Math. Res. Lett.18(6) (2011), 1239–1257] published a computational shortcut for the $\tau $ invariant of knots that can be represented by diagonal grid diagrams. Previously, the only knots known to have diagonal grid diagram representations were torus knots. We prove that all such knots are positive knots and we produce an example of a knot with a diagonal grid diagram representation which is not a torus knot.
To describe the real-world clinical impact of a commercially available plasma cell-free DNA metagenomic next-generation sequencing assay, the Karius test (KT).
Methods:
We retrospectively evaluated the clinical impact of KT by clinical panel adjudication. Descriptive statistics were used to study associations of diagnostic indications, host characteristics, and KT-generated microbiologic patterns with the clinical impact of KT. Multivariable logistic regression modeling was used to further characterize predictors of higher positive clinical impact.
Results:
We evaluated 1000 unique clinical cases of KT from 941 patients between January 1, 2017–August 31, 2023. The cohort included adult (70%) and pediatric (30%) patients. The overall clinical impact of KT was positive in 16%, negative in 2%, and no clinical impact in 82% of the cases. Among adult patients, multivariable logistic regression modeling showed that culture-negative endocarditis (OR 2.3; 95% CI, 1.11–4.53; P .022) and concern for fastidious/zoonotic/vector-borne pathogens (OR 2.1; 95% CI, 1.11–3.76; P .019) were associated with positive clinical impact of KT. Host immunocompromised status was not reliably associated with a positive clinical impact of KT (OR 1.03; 95% CI, 0.83–1.29; P .7806). No significant predictors of KT clinical impact were found in pediatric patients. Microbiologic result pattern was also a significant predictor of impact.
Conclusions:
Our study highlights that despite the positive clinical impact of KT in select situations, most testing results had no clinical impact. We also confirm diagnostic indications where KT may have the highest yield, thereby generating tools for diagnostic stewardship.
The interaction between national constitutions and transnational sources of law (foreign and international) has generated quite an active disagreement in the United States about what these bodies of law have to do with each other. This paper will explore these debates and the postures towards transnational law and its role in domestic constitutional adjudication which they express. It will identify three postures — of convergence, of resistance, and of engagement — that are manifest in the opinions of different justices of important high courts around the world, and will argue for a posture of ‘engagement’ at least in established constitutional systems like that of the United States.