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Patient- and proxy-reported outcomes (PROs) are an important indicator of healthcare quality and can be used to inform treatment. Despite the widescale use of PROs in adult cardiology, they are underutilised in paediatric cardiac care. This study describes a six-center feasibility and pilot experience implementing PROs in the paediatric and young adult ventricular assist device population.
Methods:
The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) is a collaborative learning network comprised of 55 centres focused on improving clinical outcomes and the patient/family experience for children with heart failure and those supported by ventricular assist devices. The development of ACTION’s PRO programme via engagement with patient and parent stakeholders is described. Pilot feasibility, patient/parent and clinician feedback, and initial PRO findings of patients and families receiving paediatric ventricular assist support across six centres are detailed.
Results:
Thirty of the thirty-five eligible patients (85.7%) were enrolled in the PRO programme during the pilot study period. Clinicians and participating patients/parents reported positive experiences with the PRO pilot programme. The most common symptoms reported by patients/parents in the first month post-implant period included limitations in activities, dressing change distress, and post-operative pain. Poor sleep, dressing change distress, sadness, and fatigue were the most common symptoms endorsed >30 days post-implant. Parental sadness and worry were notable throughout the entirety of the post-implant experience.
Conclusions:
This multi-center ACTION learning network-based PRO programme demonstrated initial success in this six-center pilot study experience and yields important next steps for larger-scale PRO collection, research, and clinical intervention.
The analysis of processing standards alongside samples for quality assurance in radiocarbon (14C) analyses is critical. Ideally, these standards should be similar both in nature and age to unknown samples. A new compound-specific approach was developed at the University of Bristol for dating pottery vessels using palmitic and stearic fatty acids extracted from within the clay matrix and isolated by preparative capillary gas chromatography. Obtaining suitable potsherds for use as processing standards in such analyses is not feasible, so we suggest that bog butter represents an ideal material for such purposes. We sampled ca. 450 g from two bog butter specimens and homogenized them by melting. We verified the homogeneity of both specimens by characterization of their lipid composition, δ13C values of individual lipids, and both bulk- and compound-specific radiocarbon analyses on 10 sub-samples of each bog butter specimen. The weighted means of all 14C measurements on the bog butter standards are 3777 ± 4 BP (IB33) and 338 ± 3 BP (IB38), thereby providing age-relevant standards for archaeological and historical fatty acids and ensuring the accuracy of radiocarbon determinations of lipids using a compound-specific approach. These new secondary standards will be subjected to an intercomparison exercise to provide robust consensus values.
The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs.
Design
Before-and-after intervention study.
Settings
Tertiary-care hospital.
Patients
Consecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital.
Methods
The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists’ prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle.
Results
Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment.
Conclusions
A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.
The equation of state of Fo90 hydrous ringwoodite has been measured using X-ray powder diffraction to 45 GPa at the GSECARS beam line at the Advanced Photon Source synchrotron at Argonne National Laboratory. The sample was synthesized at 1400°C and 20 GPa in the 5000 ton multi anvil press at Bayerisches Geoinstitut in Bayreuth. The sample has the formula Mg1.70Fe0.192+ Fe0.023+H0.13- Si1.00O4 as determined by electron microprobe, Fourier transform infrared and Mössbauer spectroscopies, and contains ~0.79% H2O by weight. Compression of the sample had been been measured previously to 11 GPa by single crystal X-ray diffraction. A third-order Birch-Murnaghan equation of state fit to all of the data gives V0 = 530.49±0.07 Å3, K0 = 174.6±2.7 GPa and K' = 6.2±0.6. The effect of 1% H incorporation in the structure on the bulk modulus is large and roughly equivalent to an increase in the temperature of ∼600°C at low pressure. The large value of K' indicates significant stiffening of the sample with pressure so that the effect of hydration decreases with pressure.
Thalénite-(Y), ideally Y3Si3O10F, is a heavy-rare-earth-rich silicate phase occurring in granite pegmatites that may help to illustrate rare-earth element (REE) chemistry and behaviour in natural systems. The crystal structure and mineral chemistry of thalénite-(Y) were analysed by electron microprobe analysis, X-ray diffraction and micro-Raman spectroscopy from a new locality in the peralkaline granite of the Golden Horn batholith, Okanogan County, Washington State, USA, in comparison with new analyses from the White Cloud pegmatite in the Pikes Peak batholith, Colorado, USA. The Golden Horn thalénite-(Y) occurs as late-stage sub-millimetre euhedral bladed transparent crystals in small miarolitic cavities in an arfvedsonite-bearing biotite granite. It exhibits growth zoning with distinct heavy-rare-earth element (HREE) vs. light-rare-earth element (LREE) enriched zones. The White Cloud thalénite-(Y) occurs in two distinct anhedral and botryoidal crystal habits of mostly homogenous composition. In addition, minor secondary thalénite-(Y) is recognized by its distinct Yb-rich composition (up to 0.8 atoms per formula unit (apfu) Yb). Single-crystal X-ray diffraction analysis and structure refinement reveals Y-site ordering with preferential HREE occupation of Y2 vs. Y1 and Y3 REE sites. Chondrite normalization shows continuous enrichment of HREE in White Cloud thalénite-(Y), in contrast to Golden Horn thalénite-(Y) with a slight depletion of the heaviest REE (Tm, Yb and Lu). The results suggest a hydrothermal origin of the Golden Horn miarolitic thalénite-(Y), compared to a combination of both primary magmatic followed by hydrothermal processes responsible for the multiple generations over a range of spatial scales in White Cloud thalénite-(Y).
To explore the link between nasal polyposis, refractory otitis media with effusion and eosinophilic granulomatosis with polyangiitis.
Methods:
A retrospective observational study was carried out of patients diagnosed with refractory otitis media with effusion necessitating grommet insertion and who had nasal polyps. Patients were evaluated to determine if they fulfilled the diagnostic criteria of eosinophilic granulomatosis with polyangiitis.
Results:
Sixteen patients (10 males and 6 females) were identified. The mean age of grommet insertion was 45.4 years. The mean number of grommets inserted per patient was 1.6. The mean number of nasal polypectomies was 1.7. All 16 patients had paranasal sinus abnormalities and otitis media with effusion, 14 had asthma, 9 had serological eosinophilia and 7 had extravascular eosinophilia. Nine patients met the diagnostic criteria for eosinophilic granulomatosis with polyangiitis.
Conclusion:
The co-presence of nasal polyps and resistant otitis media with effusion should raise the possibility of eosinophilic granulomatosis with polyangiitis.
We describe a simple model for turbulence in a marginally unstable, forced, stratified shear flow. The model illustrates the essential physics of marginally unstable turbulence, in particular the tendency of the mean flow to fluctuate about the marginally unstable state. Fluctuations are modelled as an oscillatory interaction between the mean shear and the turbulence. The interaction is made quantitative using empirically established properties of stratified turbulence. The model also suggests a practical way to estimate both the mean kinetic energy of the turbulence and its viscous dissipation rate. Solutions compare favourably with observations of fluctuating ‘deep cycle’ turbulence in the equatorial oceans.
This article examines the changes in herbicide use in relation to canola production in Western Canada, comparing 1995 and 2006. The commercialization and widespread adoption of herbicide-resistant (HR) canola has changed weed management practices in Western Canada. Before the introduction of HR canola, weeds were controlled by herbicides and tillage as the leading herbicides at that time required tillage to allow for soil incorporation of the herbicide. Much of the tillage associated with HR canola production has been eliminated as 64% of producers are now using zero or minimum tillage as their preferred form of crop and soil management. Additionally, there have been significant changes regarding the use and application of herbicides for weed control in canola. This research shows that when comparing canola production in 1995 and 2006, the environmental impact of herbicides applied to canola decreased 53%, producer exposure to chemicals decreased 56%, and quantity of active ingredient applied decreased 1.3 million kg. The cumulative environmental impact was reduced almost 50% with the use of HR herbicides. If HR canola had not been developed and Canadian canola farmers continued to use previous production technologies, the amount of active ingredient applied to control weeds in 2007 would have been 60% above what was actually applied.
Several approaches can be used to terminate legume cover crops in the spring prior to planting summer crops, but the effect that these methods have on decomposition and nitrogen (N) release dynamics of legume cover-crop roots is poorly understood. The main objectives of this study were to: (i) quantify decomposition and N release of roots from pea (Pisum sativum), clover (Trifolium incarnatum) and vetch (Vicia villosa Roth); (ii) determine if roots decompose and release N faster when cover crops are terminated by disking compared with roller-crimping; and (iii) determine if roots decompose and release N faster under higher soil inorganic N levels. Two field experiments were conducted in Goldsboro and Kinston, North Carolina in the summer of 2012. Cover crops at these sites were terminated in spring by disking or roller-crimping and planted to unirrigated corn. Air-dried roots placed in litterbags were buried in their corresponding cover-crop plots and in plots where cover crops had not been grown that had either synthetic N fertilizer added at burial or had no fertilizer addition. Root litterbags were collected over 16 weeks at both sites. Cover-crop plots terminated by disking had up to 117 and 49% higher soil inorganic N than roller-crimped plots in Goldsboro and Kinston, respectively. However, roots did not appear to contribute significantly to these increases, as measured root decomposition and N release was not affected by termination approach at either site. Roots decomposed rapidly at both sites, losing up to 65% of their original biomass within 4 weeks after burial. Root N release was also rapid at both sites, with vetch generally releasing N fastest and clover slowest. It was estimated that cover-crop roots supplied 47–62 and 19–33 kg N ha−1 during the corn cycle in Goldsboro and Kinston, respectively. Our results indicate that under the warm, humid summer conditions of the Southeastern USA, legume cover-crop roots decompose and release N rapidly.
To evaluate the outcomes of patients with giant pituitary tumours (GPTs) who underwent a purely binasal endoscopic transsphenoidal surgery (BETS) and compare their outcomes with those achieved through craniotomy and microscopic transsphenoidal surgery (MTS).
Methods:
Seventy-two consecutive patients with GPTs (greater than 10 cm3 in volume) who were treated surgically with BETS, craniotomy, or MTS from October 1994 to July 2009 were reviewed for clinical outcomes, degree of tumor resection, recurrence rates, and surgical complications.
Results:
The BETS group had significantly better mean reduction of tumor volume (91%) than the craniotomy (63%, p = 0.001), and the MTS (63%, p = 0.010) groups. Gross total resection rates were also higher for BETS patients than for craniotomy patients (p = 0.010). Improvements in vision and headaches were noted in 96% and 100% of patients in the BETS group, respectively; these rates were similar to those in the craniotomy and MTS groups. Of the four patients with hormone-secreting tumours in the BETS group, three remained in remission. The median length-of-stay (four days) for the BETS group was shorter (p = 0.010), and surgical complications were less frequent (p = 0.037) and less severe compared to the craniotomy group. There were no differences in the recurrence rates: 79% percent of patients in the BETS group, 69% in the craniotomy group, and 79% in the MTS group were recurrence free at last follow-up (p = 0.829).
Conclusions:
Treatment of GPT with BETS offers excellent oncologic and clinical outcomes and can frequently obviate the need for craniotomy in these patients.
Cushing disease (CD) constitutes a challenging condition for the pituitary surgeon. Given the variety of factors affecting outcomes in CD, it is uncertain whether the newer endoscopic technique improves the results of surgery.
Methods:
A review was conducted of CD cases at our institution between 2000 and 2010. Analysis was done to: determine if surgical technique had an effect on outcome, identify the predictors of outcome and provide details of failed cases. Remission was defined as normal postoperative 24-hour urinary free cortisol (24-h UFC), suppression of morning serum cortisol to <50 nmol/L after 1mg of dexamethasone or being dependent on steroid replacement.
Results:
Forty-two patients met our inclusion criteria. Average follow-up period was 33 months. There were 15 macroadenomas and 27 microadenomas. Seventeen patients had an endoscopic transsphenoidal surgery and twenty-five patients had a microscopic transsphenoidal procedure. Long-term overall remission was achieved in 26 (62%) patients. There was no significant difference in remission rates between the two techniques (p value 0.757). Patient's subjective symptomatic improvement and drop of morning serum cortisol in the postoperative period to less than 100 nmol/L correlated with long-term remission (p value 0.0031and 0.0101, respectively) while repeat surgery was the only predictor of the lack of postoperative remission (p value 0.0008).
Conclusions:
Revision surgery predicted poor remission rate for CD. Within the power of our study size, there was no difference in outcome between the endoscopic and microscopic approaches. Surgical outcomes should be reviewed in association with remission criteria used in a study.
General Practitioner consultation rates for influenza-like illness (ILI) are monitored through several geographically distinct schemes in the UK, providing early warning to government and health services of community circulation and intensity of activity each winter. Following on from the 2009 pandemic, there has been a harmonization initiative to allow comparison across the distinct existing surveillance schemes each season. The moving epidemic method (MEM), proposed by the European Centre for Disease Prevention and Control for standardizing reporting of ILI rates, was piloted in 2011/12 and 2012/13 along with the previously proposed UK method of empirical percentiles. The MEM resulted in thresholds that were lower than traditional thresholds but more appropriate as indicators of the start of influenza virus circulation. The intensity of the influenza season assessed with the MEM was similar to that reported through the percentile approach. The MEM pre-epidemic threshold has now been adopted for reporting by each country of the UK. Further work will continue to assess intensity of activity and apply standardized methods to other influenza-related data sources.
Cystic fibrosis (CF) is an inherited childhood-onset life-shortening disease. It is characterized by increased respiratory production, leading to airway obstruction, chronic lung infection and inflammatory reactions. The most common bacteria causing persisting infections in people with CF is Pseudomonas aeruginosa. Superparamagnetic Fe3O4 iron oxide nanoparticles (NPs) conjugated to the antibiotic (tobramycin), guided by a gradient of the magnetic field or subjected to an oscillating magnetic field, show promise in improving the drug delivery across the mucus and P. aeruginosa biofilm to the bacteria. The question remains whether tobramycin needs to be released from the NPs after the penetration of the mucus barrier in order to act upon the pathogenic bacteria. We used a zero-length 1-ethyl-3-[3-dimethylaminopropyl] carbodiimide hydrochloride (EDC) crosslinking agent to couple tobramycin, via its amine groups, to the carboxyl groups on Fe3O4 NPs capped with citric acid. The therapeutic efficiency of Fe3O4 NPs attached to the drug versus that of the free drug was investigated in P. aeruginosa culture.
An analysis was undertaken to measure age-specific vaccine effectiveness (VE) of 2010/11 trivalent seasonal influenza vaccine (TIV) and monovalent 2009 pandemic influenza vaccine (PIV) administered in 2009/2010. The test-negative case-control study design was employed based on patients consulting primary care. Overall TIV effectiveness, adjusted for age and month, against confirmed influenza A(H1N1)pdm 2009 infection was 56% (95% CI 42–66); age-specific adjusted VE was 87% (95% CI 45–97) in <5-year-olds and 84% (95% CI 27–97) in 5- to 14-year-olds. Adjusted VE for PIV was only 28% (95% CI −6 to 51) overall and 72% (95% CI 15–91) in <5-year-olds. For confirmed influenza B infection, TIV effectiveness was 57% (95% CI 42–68) and in 5- to 14-year-olds 75% (95% CI 32–91). TIV provided moderate protection against the main circulating strains in 2010/2011, with higher protection in children. PIV administered during the previous season provided residual protection after 1 year, particularly in the <5 years age group.
The cestodes, or tapeworms, are a group of parasitic worms many species of which cause serious, often fatal, diseases in man and domestic animals throughout the world. This book is an updated and expanded version of Professor Smyth's The Physiology of Cestodes (1969). The text has now been entirely rewritten, taking into account advances in investigative techniques such as immunocytochemistry, in vitro culture and scanning electron microscopy, which have immensely increased our understanding of these organisms. The biochemical coverage now includes the spectacular advances in molecular biology that have occured. The book also shows how cestodes are increasingly being recognized as valuable models for investigating fundamental biological phenomena such as membrane transport and asexual/sexual differentiation. Students of medicine, veterinary medicine, parasitology and zoology will find this book invaluable. Its high research content and extensive references also make it an essential reference book for researchers in these fields.
Self insemination appears to be the normal process of sperm transfer in Echinococus granulosus and has been observed in both terminal and subterminal proglottids of worms from dogs.
Cross fertilization between adjacent proglottids or between proglottids of different strobila was not observed.
In some instances, the genital pore was found occluded by a ‘plug’ of material which may represent an antige–antibody precipitate.
The implications of self-insemination in relation to in vitro studies and to the genetics of ‘strain’ production in the genus Echinococcus are discussed.
Attention has been drawn to the fact that the occurrence of the cystic stage of Echinococcus granulosus in 60% of slaughtered horses represents a potential public health hazard (Thompson and Smyth, 1974). Williams and Sweatman (1963) regard this organism as a separate sub-species, E. granulosus equinus distinct from E. granulosus granulosus, but we prefer at this stage to refer to it as the horse “strain” which exhibits some small morphological differences from organisms of sheep origin.