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[...]it was not long before critics of the Bush Administration's conduct of the \"war on terror\" blamed the Clash of Civilizations thesis for blurring the distinction between radical Islamist groups and Islamic civilization as a whole, thereby fueling a false narrative of fundamental conflict between Islam and the West.1 Lost in the controversy was Huntington's admonition that the United States should minimize the clash of civilizations by accepting the need to coexist, and especially to avoid cross-civilizational interventions.2 The enduring validity of Huntington's thesis is that significant cultural differences limit prospects for a global community based on universal values, and that failure to accommodate such differences can be damaging to both order and justice in international politics. A year later Francis Fukuyama argued that with the defeat of fascism and communism, liberal democracy and free market economics had no more serious ideological rivals. [...]international conflict would diminish as more countries became democracies and shared the democratic values growing out of American and Western European political culture.4 But Huntington also cautioned that the \"wave\" of democracy could be reversed, as it had been before. [...]doing so would risk badly damaging relations with Russia. [...]it was necessary to compromise the official commitment to justice for the sake of order. [...]universal norms are irrelevant if they cannot be related meaningfully to a country's already existing laws, are perceived as alien to its political culture, or are not politically compatible with the interests of those in power.

Little is known about the consequences of intensivists’ work schedules, or intensivist continuity of care. To assess the impact of weekend respite for intensivists, with consequent reduction in continuity of care, on them and their patients. In five medical intensive care units (ICUs) in four academic hospitals we performed a prospective, cluster-randomized, alternating trial of two intensivist staffing schedules. Daily coverage by a single intensivist in half-month rotations (continuous schedule) was compared with weekday coverage by a single intensivist, with weekend cross-coverage by colleagues (interrupted schedule). We studied consecutive patients admitted to study units, and the intensivists working in four of the participating units. The primary patient outcome was ICU length of stay (LOS);we also assessed hospital LOS and mortality rates. The primary intensivist outcome was physician burnout. Analysis was by multivariable regression. A total of 45 intensivists and 1,900 patients participated in the study. Continuity of care differed between schedules (patients with multiple intensivists = 28% under continuous schedule vs. 62% under interrupted scheduling; P < 0.0001). LOS and mortality were nonsignificantly higher under continuous scheduling (ΔICU LOS 0.36 d, P = 0.20; Δhospital LOS 0.34 d, P = 0.71; ICU mortality, odds ratio = 1.43, P = 0.12; hospital mortality, odds ratio = 1.17,P = 0.41). Intensivists experienced significantly higher burnout, work–home life imbalance, and job distress working under the continuous schedule. Work schedules where intensivists received weekend breaks were better for the physicians and, despite lower continuity of intensivist care, did not worsen outcomes for medical ICU patients.

More than a million polysomnograms (PSGs) are performed annually in the United States to diagnose obstructive sleep apnea (OSA). Third-party payers now advocate a home sleep test (HST), rather than an in-laboratory PSG, as the diagnostic study for OSA regardless of clinical probability, but the economic benefit of this approach is not known. We determined the diagnostic performance of OSA prediction tools including the newly developed OSUNet, based on an artificial neural network, and performed a cost-minimization analysis when the prediction tools are used to identify patients who should undergo HST. The OSUNet was trained to predict the presence of OSA in a derivation group of patients who underwent an in-laboratory PSG (n = 383). Validation group 1 consisted of in-laboratory PSG patients (n = 149). The network was trained further in 33 patients who underwent HST and then was validated in a separate group of 100 HST patients (validation group 2). Likelihood ratios (LRs) were compared with two previously published prediction tools. The total costs from the use of the three prediction tools and the third-party approach within a clinical algorithm were compared. The OSUNet had a higher +LR in all groups compared with the STOP-BANG and the modified neck circumference (MNC) prediction tools. The +LRs for STOP-BANG, MNC, and OSUNet in validation group 1 were 1.1 (1.0-1.2), 1.3 (1.1-1.5), and 2.1 (1.4-3.1); and in validation group 2 they were 1.4 (1.1-1.7), 1.7 (1.3-2.2), and 3.4 (1.8-6.1), respectively. With an OSA prevalence less than 52%, the use of all three clinical prediction tools resulted in cost savings compared with the third-party approach. The routine requirement of an HST to diagnose OSA regardless of clinical probability is more costly compared with the use of OSA clinical prediction tools that identify patients who should undergo this procedure when OSA is expected to be present in less than half of the population. With OSA prevalence less than 40%, the OSUNet offers the greatest savings, which are substantial when the number of sleep studies done annually is considered.

ICU-acquired paresis (ICUAP) is common in survivors of critical illness. There is significant associated morbidity, including prolonged time on the ventilator and longer hospital stay. However, it is unclear whether ICUAP is independently associated with mortality, as sicker patients are more prone and existing studies have not adjusted for this. To test the hypothesis that ICUAP is independently associated with increased mortality. Secondarily, to determine if handgrip dynamometry is a concise measure of global strength and is independently associated with mortality. A prospective multicenter cohort study was conducted in intensive care units (ICU) of five academic medical centers. Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength. We measured global strength and handgrip dynamometry. The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days, ICU readmission, and recurrent respiratory failure. Subjects with ICUAP (average MRC score of < 4) had longer hospital stays and required mechanical ventilation longer. Handgrip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP. After adjustment for severity of illness, ICUAP was independently associated with hospital mortality (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.4-25.3; P = 0.001). Separately, handgrip strength was independently associated with hospital mortality (OR, 4.5; 95% CI, 1.5-13.6; P = 0.007). ICUAP is independently associated with increased hospital mortality. Handgrip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP. Clinical trial registered with www.clinicaltrials.gov (NCT00106665).

Samuel Huntington's argument that deep cultural differences have been fundamental to conflict in the contemporary world first appeared in a journal article in 1993.1 His thesis became the center of attention eight years later as an explanation for the violence unleashed on New York City in the name of Islam. 2 The term \"peaceful coexistence,\" redolent of the Cold War, is indicative of the widespread impression that, for Huntington, a global, ideological confrontation between radical Muslims and the United States is but a new version of the titanic struggle between the forces of communism and the United States, leader now as then of the \"Free World.\" Multilateral intervention as a force behind liberal internationalism (epitomized by the idea of human rights) and globalization as the irrepressible urge of free trade dominated discourse in international politics during most of the 1990s. The argument that culture (including religion) is at least as important as economic or political factors in explaining stable democracy or civil strife has been central to some of the most influential work over the past ten years, such as that of Robert Putnam and Michael Ignatieff.6 The Clash of Civilizations similarly argues that cultural factors play a considerably larger role in international conflict than hitherto realized.

The East German government's commemoration in 1983 of the 500th anniversary of Martin Luther's birth exemplifies its continuing effort to broaden domestic support by arguing over a thirty-year period that the regime's values are deeply rooted in German civilization. The representation of Luther in the German Democratic Republic has evolved from caricature to sophisticated portraiture. Fundamental to this reinterpretation has been the association of Luther with the bourgeois-democratic revolution, a process which the ruling Socialist Unity party claims to have completed in the course of establishing the GDR. Continuing interaction between East and West Germany has complicated the GDR's effort to utilize historical symbols in developing a unified political culture.