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Most people who develop dementia will never be diagnosed, and therefore lack access to treatment and care from specialists in the field. This new edition provides updated guidance on how behavioral symptom reflect the changes occurring in the brain, and how these can help generalist clinicians to accurately diagnose neurodegenerative diseases. This practical book is aimed at healthcare professionals working in neurology, psychiatry and neuropsychology wanting to enhance the skills and knowledge needed to successfully manage these diseases. Simple approaches to bedside mental status testing, differential diagnosis and treatment, and interpreting neuropsychological testing and neuroimaging findings are covered. Introductory chapters outline dementia epidemiology and dementia neuropathology whilst chapters new to this edition describe the improvements in diagnostic capabilities in recent years, including blood based and cerebrospinal biomarkers and emerging biologically based therapies. Chapters on sleep disorders, and chronic traumatic encephalopathy and traumatic brain injury have also been expanded.
The fly Heleomyza serrata (Linnaeus) (Diptera: Heleomyzidae) is reported to range widely throughout the United States of America and Canada. However, in Eurasia, this species is restricted to northern regions; in central and southern Europe, H. serrata is replaced by the similar species H. captiosa (Gorodkov), which can be distinguished from H. serrata by the male genitalia. We report H. captiosa from Kentucky, United States of America, the first Nearctic record of this species. The taxonomy of Nearctic Heleomyza Fallén is discussed, and we propose to transfer three species to the genus Scoliocentra Loew: Scoliocentra (Scoliocentra) bisetata (Garrett) comb. nov., S. (Leriola Gorodkov) latens (Aldrich) comb. nov., and S. (L.) nebulosa (Coquillett) comb. nov. We recognise Anypotacta Czerny as a subgenus of Heleomyza and transfer the two Nearctic species to that genus: H. (A.) aldrichi Garrett comb. nov. and H. (A.) gillinom. nov. (new replacement name for Anypotacta czernyi Gill, 1962). Finally, we provide an updated key to Nearctic Heleomyza and morphologically similar species of Scoliocentra. Further study will be required to ascertain the range and abundance of H. captiosa in North America.
We present the serendipitous radio-continuum discovery of a likely Galactic supernova remnant (SNR) G305.4–2.2. This object displays a remarkable circular symmetry in shape, making it one of the most circular Galactic SNRs known. Nicknamed Teleios due to its symmetry, it was detected in the new Australian Square Kilometre Array Pathfinder (ASKAP) Evolutionary Map of the Universe (EMU) radio–continuum images with an angular size of 1 320$^{\prime\prime}$$\times$1 260$^{\prime\prime}$ and PA = 0$^\circ$. While there is a hint of possible H$\alpha$ and gamma-ray emission, Teleios is exclusively seen at radio–continuum frequencies. Interestingly, Teleios is not only almost perfectly symmetric, but it also has one of the lowest surface brightnesses discovered among Galactic SNRs and a steep spectral index of $\alpha$=–0.6$\pm$0.3. Our best estimates from Hi studies and the $\Sigma$–D relation place Teleios as a type Ia SNR at a distance of either $\sim$2.2 kpc (near-side) or $\sim$7.7 kpc (far-side). This indicates two possible scenarios, either a young (under 1 000 yr) or a somewhat older SNR (over 10 000 yr). With a corresponding diameter of 14/48 pc, our evolutionary studies place Teleios at the either early or late Sedov phase, depending on the distance/diameter estimate. However, our modelling also predicts X-ray emission, which we do not see in the present generation of eROSITA images. We also explored a type Iax explosion scenario that would point to a much closer distance of $\lt$1 kpc and Teleios size of only $\sim$3.3 pc, which would be similar to the only known type Iax remnant SN1181. Unfortunately, all examined scenarios have their challenges, and no definitive Supernova (SN) origin type can be established at this stage. Remarkably, Teleios has retained its symmetrical shape as it aged even to such a diameter, suggesting expansion into a rarefied and isotropic ambient medium. The low radio surface brightness and the lack of pronounced polarisation can be explained by a high level of ambient rotation measure (RM), with the largest RM being observed at Teleios’s centre.
How did resource use, trade, and patterns of everyday life change at visita mission towns in the early decades of the colonial period in northern Yucatán, Mexico? We consider this question with an analysis of archaeological material assemblages from the site of Hunacti, occupied from 1557 to 1572. Household archaeology performed at three elite residences and investigations at the central plaza and church provide evidence of continuity, change, and metrics for assessing relative prosperity by which Hunacti can be compared to its contemporaries. This spectacularly built mission town evinces several signs of initial wealth and privilege enjoyed by the site’s Maya elites, but historical records reveal relentless persecution of these leaders for idolatry, which affected the longer-term prospects of the settlement. Our findings indicate the persistence of Maya religious rites through the site’s occupation, the importance of traditional Maya tools and technologies, and relative impoverishment (as conventionally measured). These patterns offer a profile of material life at a site that chose, ultimately, abiding resistance—and consequently, greater local self-sufficiency—in the face of accelerating external scrutiny and persecution.
This article explores the extent to which listeners vary in their ability to notice, identify and discriminate variable linguistic features. With a view to improving speaker evaluation studies (SES), three types of experiments were conducted (noticing tasks, identification tasks and discrimination tasks) with regard to variable features using word- or sentence-based stimuli and focusing on three variables and their variants – (ING): [ɪŋ], [ɪn]; (T)-deletion: [t], deleted-[t]; (K)-lenition: [k], [x]. Our results suggest that the accurate noticing, identifying and discriminating of variants is somewhat higher in words than in sentences. Correctness rates differ drastically between variants of a variable. For (ING), the non-standard variant [ɪn] is more frequently identified and noticed correctly. Yet, for the variables (T)-deletion and (K)-lenition, the standard variants are identified and noticed more successfully. Results of the current study suggest that a more rigorous elicitation of identification and noticing abilities might be useful for a more complete understanding of the nature of social evaluation.
Branched broomrape [Phelipanche ramosa (L.) Pomel], a parasitic weed with a broad host range, is a quarantine pest in California. Phelipanche ramosa plants can produce thousands of tiny seeds that are easily spread by farm equipment. Best management practices for reducing dispersal risk include physical cleaning and disinfestation of farm equipment, but data on the efficacy of sanitizers on weed seeds are limited. A three-phase study was undertaken during 2022 to 2023 to evaluate quaternary ammonium compound (QAC) sanitizer efficacy on P. ramosa seed germinability. First, several QAC ingredients were evaluated at various concentrations (0 to 2.5 g per 100 ml) and exposure durations (1, 3, and 5 min) to develop initial germination curves. Second, the experiments were conducted with three commercial QAC sanitizers (MG4-Quat [Mg4], Flo-Quat, and Cleaner QT-185) at the recommended dose (1% v/v) and a field-relevant exposure duration (1 min). The final experiments evaluated commercial QAC sanitizer efficacy in the presence of various debris types. The initial experiments showed that alkyl dimethyl benzyl ammonium chloride (ADAC), didecyl dimethyl ammonium bromide (DDAB), and didecyl dimethyl ammonium chloride (DDAC) effectively prevented P. ramosa germination, but the effective dose for a 50% reduction in P. ramosa seed germination ranged from 0.001% (g per 100 ml) at 10 min with DDAC to 0.35% (g per 100 ml) at 1 min with ADAC. While all three QAC sanitizers reduced seed germination 75% to 100% after a 1-min exposure to the recommended dose (1% v/v), this treatment did not affect seed germination in the presence of soil (100 mg ml−1) or fruit/plant tissue (40 mg ml−1). At higher concentrations of Mg4 (8% v/v), P. ramosa seed germination was reduced by 90% to 100%, even in the presence of soil and plant debris. This study demonstrates that while QAC sanitizers can reduce P. ramosa seed germinability, their efficacy is compromised in the presence of debris. Therefore, physical cleaning to reduce debris loads before QAC application is essential for reducing the risk of P. ramosa seed movement among fields on equipment.
We present the first radio–continuum detection of the circumstellar shell around the well-known WN8 type Wolf-Rayet star WR16 at 943.5 MHz using the Australian Square Kilometre Array Pathfinder (ASKAP) Evolutionary Map of the Universe (EMU) survey. At this frequency, the shell has a measured flux density of 72.2$\pm$7.2 mJy. Using previous Australia Telescope Compact Array (ATCA) measurements at 2.4, 4.8, and 8.64 GHz, as well as the Evolutionary Map of the Universe (EMU) observations of the star itself, we determine a spectral index of $\alpha\,=\,+0.74\pm0.02$, indicating thermal emission. We propose that the shell and star both exhibit thermal emission, supported by the its appearance in near-infrared and H$\alpha$ observations. The latest Gaia parallax is used to determine a distance of 2.28$\pm$0.09 kpc. This star is well known for its surrounding circular nebulosity, and using the distance and an angular diameter of $8.^{\prime}42$, we determine the shell size to be 5.57$\pm$0.22 pc. We use the Gaia proper motion (PM) of WR16 to determine peculiar velocities of the star as $V_{\alpha}(pec) =$ –45.3$\pm$5.4 km s$^{-1}$ and $V_{\delta}(pec) =$ 22.8$\pm$4.7 km s$^{-1}$, which indicates that the star is moving in a north-west direction, and translates to a peculiar tangential velocity to be 50.7$\pm$6.9 km s$^{-1}$. We also use these proper motion (PM) to determine the shell’s origin, estimate an age of $\sim 9500\pm 1300$ yr, and determine its average expansion velocity to be $280\pm40$ km s$^{-1}$. This average expansion velocity suggests that the previous transitional phase is a Luminous Blue Variable (LBV) phase, rather than a Red Super Giant (RSG) phase. We also use the measured flux at 943.5 MHz to determine a mass-loss rate of $1.753\times 10^{-5}\,{\rm M}_\odot\,$yr$^{-1}$, and use this to determine a lower-limit on ionising photons of $N_{UV} \gt 1.406\times 10^{47}\,\textit{s}^{-1}$.
“Frailty” is associated with worse outcomes in adult cardiology. There is limited data on the associations between frailty and outcomes in paediatric cardiology. We aimed to define the prevalence of frailty and identify associations between frailty and neurodevelopmental and quality-of-life outcomes in high-risk paediatric cardiac populations.
Study Design:
This cross-sectional study included patients 4–18 years seen in a neurodevelopmental programme between 6/2017 and 11/2022. Demographic and clinical data were obtained from medical records. As part of the routine care, physical therapy assessment and neurocognitive, psychosocial, adaptive functioning, and quality-of-life surveys were administered. Social determinants of health were assessed by insurance status and Childhood Opportunity Index. Frailty was defined as the abnormality in 3 of 5 categories: body composition, weakness, slowness, physical activity, and exhaustion. Chi-Square, Student t, and Wilcoxon Rank Sum tests were used to assess differences between frail and non-frail groups.
Results:
Of the 270 patients, 101 (37%) met the frailty criteria. Frailty was not associated with social determinants of health, cardiac diagnosis, genetic syndrome, number of cardiac surgeries, or history of clinical complications. Frail patients were more likely to be older (p = 0.004) and have neurocognitive (p = 0.024), emotional (p = 0.003), social (p < 0.001), motor (p < 0.001), and adaptive dysfunction (p < 0.001) and lower quality of life (p = 0.029).
Conclusion:
Frailty is common in school-aged patients with cardiac disease and is associated with adverse neurocognitive, psychosocial, motor, and adaptive outcomes and worse quality of life. Risk stratification for frailty may be a critical evaluation and screening element of high-risk cardiac patients in neurodevelopmental programmes.
Clinical rotations should introduce students to the patient types/conditions appropriate for an observation unit (OU), to differentiate factors for observation from inpatient services, to risk stratification, and to disposition decision making. Observation medicine fellowships allow the fellow to gain expertise in the administrative as well as clinical aspects of observation medicine and provide an opportunity for research. Observation medicine may be part of an emergency medicine administration fellowship.
Plant invader genotype determines much about how the plant establishes, spreads, and impacts receiving habitat and the types of management required to achieve its control. We investigated phenology, vegetative spread, growth and biomass allocation, and response to herbicides of four flowering rush (Butomus umbellatus L.) amplified fragment length polymorphism (AFLP) genotypes (triploid: GT1; diploid: GT3, GT4, GT5) in a multiyear mesocosm experiment. Monthly observations were made over 31 mo to determine whether there were differences in timing of peak plant growth and flowering. We also applied herbicides during years 2 and 3 using imazamox or triclopyr at rates previously determined to be efficacious against B. umbellatus. By the end of year 1, all genotypes spread vegetatively within their containers. From a single sprouted axillary bud (i.e., bulbil), GT4 plants spread to cover nearly 2,000 cm2 in 6 mo. Flowering occurred May through October for all genotypes, but was reduced in years 2 and 3, including almost no flowering in triploid plants after year 1. Maximum leaf abundance occurred in August or September for all genotypes. After one season of growth, biomass was greatest for diploid genotypes, allocated primarily to leaves. However, by year 3, triploid plant biomass was greater than diploid GT4 and GT5, but not GT3. Bulbil production occurred only in diploid genotypes. At the study conclusion, GT4 and GT5 produced nearly 15,000 and 20,000 bulbils each, whereas GT3 plants produced fewer than 5,000 bulbils. Herbicides were effective in reducing biomass, but triploid plants were far more susceptible than diploid plants. Propagule production was generally reduced by herbicides, but rhizome bud production increased 240% in triploid plants treated with imazamox. These results demonstrate (1) the significant capacity for reproduction and spread of B. umbellatus and (2) the importance of investigating differences between lineages of B. umbellatus to inform management and risk assessments.
Quality improvement programmes (QIPs) are designed to enhance patient outcomes by systematically introducing evidence-based clinical practices. The CONQUEST QIP focuses on improving the identification and management of patients with COPD in primary care. The process of developing CONQUEST, recruiting, preparing systems for participation, and implementing the QIP across three integrated healthcare systems (IHSs) is examined to identify and share lessons learned.
Approach and development:
This review is organized into three stages: 1) development, 2) preparing IHSs for implementation, and 3) implementation. In each stage, key steps are described with the lessons learned and how they can inform others interested in developing QIPs designed to improve the care of patients with chronic conditions in primary care.
Stage 1 was establishing and working with steering committees to develop the QIP Quality Standards, define the target patient population, assess current management practices, and create a global operational protocol. Additionally, potential IHSs were assessed for feasibility of QIP integration into primary care practices. Factors assessed included a review of technological infrastructure, QI experience, and capacity for effective implementation.
Stage 2 was preparation for implementation. Key was enlisting clinical champions to advocate for the QIP, secure participation in primary care, and establish effective communication channels. Preparation for implementation required obtaining IHS approvals, ensuring Health Insurance Portability and Accountability Act compliance, and devising operational strategies for patient outreach and clinical decision support delivery.
Stage 3 was developing three IHS implementation models. With insight into the local context from local clinicians, implementation models were adapted to work with the resources and capacity of the IHSs while ensuring the delivery of essential elements of the programme.
Conclusion:
Developing and launching a QIP programme across primary care practices requires extensive groundwork, preparation, and committed local champions to assist in building an adaptable environment that encourages open communication and is receptive to feedback.
Aims: The At-Risk Mental State (ARMS), an attenuated psychotic syndrome, represents a critical period of vulnerability for the development of psychosis. Early identification and evidence-based intervention are crucial to reducing distress, improving long-term outcomes and public health costs. There are clear recommendations stated by National Institute for Health and Care Excellence (NICE) for the optimal management of ARMS in children and young people including early identification, access to psychological therapy and care co-ordination. Baseline audit data collected from Tier 3 teams within South West London and St George’s NHS Mental Health Trust (SWLSTG) highlighted significant variation in clinicians’ confidence and knowledge about ARMS, notably its identification criteria and optimal management. This audit sought to enhance clinician expertise of “At Risk Mental State” (ARMS) within Tier 3 Child and Adolescent Mental Health Services (CAMHS).
Methods: An educational intervention was developed to address the identified knowledge gaps. This included a 30-minute didactic teaching seminar covering ARMS diagnostic criteria, clinical challenges, and management guidelines, delivered during the CPD slot for four multidisciplinary teams across SWLSTG. Key topics included the Comprehensive Assessment of At-Risk Mental States (CAARMS), the role of psychological and family interventions, and current NHS England guidelines that included discouraging antipsychotic use in ARMS management.
Results: Post-intervention analysis showed improved clinician confidence in both ARMS identification and management. However, all participants indicated a need for additional support. Proposed ideas included specialist training (e.g. CBT for Psychosis and Family Interventions for Psychosis), access to validated assessment tools, appropriate funding for care co-ordination and/or the establishment of a dedicated ARMS service. Qualitative feedback also emphasised the diagnostic difficulty in this population and sociodemographic bias when identifying ARMS within CAMHS settings, highlighting the need for a public health approach to prevention of psychosis.
Conclusion: This project illustrates the effectiveness of a simple targeted educational initiative in improving ARMS-related competencies among Tier 3 CAMHS clinicians. It also highlights the importance of integrating structured tools and specialised pathways to optimise care for individuals at high risk of psychosis. Our next steps are to consider strategies to improve the standard of care provided for young people with ARMS. This includes further psychoeducation resources and a funding application for specialist training for Tier 3 psychologists.
Aims: Doctors in training report high rates of burnout. The Balint group lends itself to addressing emotional stress and hence the associated risk of burnout. However, Balint group attendance among GP trainees and foundation doctors locally has been poor compared with psychiatric trainees. A Quality Improvement project was undertaken to explore and address barriers to attendance with the aim of improving GP trainees’ and foundation doctors’ engagement with the Balint group.
Methods: QI methodology was used throughout 2024. We implemented a quantitative, cross-sectional design using anonymous online surveys. We used purposive sampling by sending the surveys to GP trainees and foundation doctors on psychiatric placements within Kent and Medway NHS and Social Care Partnership Trust (KMPT). The survey was semi-structured, with closed and open-ended responses. The survey explored their understanding of the Balint group, how important they perceived it to be, and the barriers they experienced to attending.
Data gathered informed several ‘change ideas’ which were implemented through consecutive plan-do-study-act (PDSA) cycles. The timing of Balint groups was changed to ensure that less-than-full-time doctors had options to attend and that groups were less likely to conflict with clinical commitments. Improvements were made to the induction process to better socialise non-psychiatric trainees with the Balint group. A face-to-face format was trialled, replacing the previous virtual format.
Post-intervention surveys were administered, which included validated measures of burnout (Abbreviated Copenhagen Burnout Inventory).
Results: Resident doctors’ understanding of the Balint group’s function and process has improved. In parallel, attendance has increased in some Balint groups; for example, 75% attendance in June 2024 compared with 25% in March 2024. However, with frequent rotations of GP trainees and foundation doctors, each cohort having its own needs and preferences, we have found that improvements are not consistently sustained. Barriers still exist, such as conflicts with clinical commitments and the format feeling ‘alien’ and unhelpful to others. Changes to the degree of burnout through attending the Balint group are inconclusive and will be clarified with the results of a follow-up survey in March 2025.
Conclusion: GP trainees and foundation doctors are better able to engage with the Balint group when barriers to attendance are actively addressed. However, not all resident doctors feel comfortable with the Balint group format, and hence it may not reduce the risk of burnout for these individuals; in such cases, attendance should not be mandated.
On the Ecclesiastical Hierarchy is part of a corpus of Greek works by an unknown author in the late fifth or early sixth century. The author wrote under the pseudonym of Dionysius the Areopagite, who according to Acts 17:34 converted after hearing Paul’s preaching. The corpus was highly influential in the Byzantine tradition, its ideas influencing authors from Maximus the Confessor to Gregory Palamas. Through various translators, the most famous being John Scotus Eriugena, it also informed many medieval Latin theologians. It was cited in papal documents and excerpted in collections of sententiae, and no less a thinker than Thomas Aquinas wrote a commentary on the Dionysian text On the Divine Names. In 1457, the humanist Lorenzo Valla demonstrated that the corpus could not have been written by the Athenian convert Dionysius, and his views were disseminated by Erasmus. Still, the corpus contains a classic statement of mystical theology and continues to be read widely today.
Shenoute of Atripe (348–465) was the most important Egyptian monastic leader in late antiquity. He developed a formalized discipline with which he governed three monasteries (two for men, one for women) located in the village of Atripe, across the Nile River from the city Panopolis (modern Akhmim). Thanks to Shenoute’s leadership, these monastic complexes, collectively known as the White Monastery Federation, played a major role in the social, political, economic, and religious lives of people in the region (Christians and non-Christians alike) and would become the hub of Christian literary culture in Egypt well into the Arab period. Shenoute himself occasionally preached public sermons in his native Coptic tongue to large crowds consisting of monastics, clergy members, lay people, government officials, military professionals, and other local luminaries. In those moments, Shenoute repeatedly defined the moral contours of the Christian community by stridently and repeatedly lambasting any zdepravity he believed present among his hearers, such as exploitation of the poor by rich landowners, adultery, violation of monastic vows, theft, cultic veneration of pagan gods, and Origenist and eventually Chalcedonian heresy.