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Seizures and epilepsy are frequently misdiagnosed. Only about 50% of patients transferred to ICUs in tertiary hospitals after presumed status epilepticus are found to have status epilepticus.1 About 90% of those misdiagnosed with epilepsy actually have psychogenic nonepileptic event (PNEE).2 There are many other disorders misdiagnosed as epilepsy, organic and nonorganic, seen in adults and children. This chapter discusses the common differential diagnoses for epilepsy in hopes of making recognition of epilepsy imitators easier. As with any disorder, misdiagnosis delays the appropriate treatment needed to provide relief to the patient. In PNEE, a completely different therapeutic approach is needed (versus epileptic seizures), including psychotherapy and psychotropic medications. Antiseizure drugs (ASDs) used in those who do not need them place an unnecessary risk of common and rare side effects.
In contrast to the literature on the applicability of civil and political rights in armed conflict and other situations of violence, internationally recognised economic, social and cultural rights have been largely ignored. The legal guarantees related to work, food, housing, healthcare, social security or education are not generally seen as a priority amid widespread armed violence, since other affected rights relating to life, liberty and security typically attract greater attention. Accordingly, protection of education has never been considered as a priority during and after armed conflict.
This study explores the experiences and practices of emergency medical services (EMS) providers, as well as the motivations that underpin perceptions toward standard infection prevention and control (IPC). The current literature suggests that EMS providers have a low compliance level with preventive measures, with misperceptions about risks and self-justification of personal skills reported.
The study used qualitative methods and conducted 2 distinct focus group discussions and 20 in-depth interviews with both prehospital and inter-facility EMS providers. Data were thematically analyzed using the Framework approach.
The participants considered respiratory infections the most significant nosocomial risks. Lack of full disclosure of medical history to EMS providers was considered a significant threat. Beliefs about low effectiveness and harmful effects of the influenza vaccine, as well as low perceptions of influenza risks, were common. While apparent misperceptions contributed largely to the inappropriate use of preventive measures, the reliance on intuition and individual experiences was attributed to the inaccessibility of appropriate guidelines, and lack of formal IPC training programs.
There is need to address EMS doubts and fears, improve IPC practices and awareness by institutionalizing IPC training programs, and ensure the design and accessibility of simplified and well-tailored IPC guidelines for EMS providers.
We sought to establish the impact on vaccine uptake of sending out a single appointment letter inviting patients to attend a vaccine clinic.
Coeliac disease is associated with splenic dysfunction and so patients with coeliac disease are at a higher risk of overwhelming infection. Additional vaccinations are recommended for these individuals to provide additional protection against infection.
We retrospectively identified 54 patients with diagnosed coeliac disease, and all vaccines previously received by these patients. By comparing this to the Green Book [Department of Health (2013) Immunisation of individuals with underlying medical conditions: the green book, chapter 7, London: Department of Health. Retrieved 26 February 2019 from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/566853/Green_Book_Chapter7.pdf], we determined the patients who were due vaccinations and the specific vaccines they were due. An invitation letter was then sent out to patients requiring further vaccinations and vaccine uptake for these patients was re-audited six months later.
Our results show a mild increase in the total uptake of vaccines six months after the letter was sent out, from 38.6% to 49.2%.
Evidence suggests that sub-optimal maternal nutrition has implications for the developing offspring. We have previously shown that exposure to a low-protein diet during gestation was associated with upregulation of genes associated with cholesterol transport and packaging within the placenta. This study aimed to elucidate the effect of altering maternal dietary linoleic acid (LA; omega-6) to alpha-linolenic acid (ALA; omega-6) ratios as well as total fat content on placental expression of genes associated with cholesterol transport. The potential for maternal body mass index (BMI) to be associated with expression of these genes in human placental samples was also evaluated. Placentas were collected from 24 Wistar rats at 20-day gestation (term = 21–22-day gestation) that had been fed one of four diets containing varying fatty acid compositions during pregnancy, and from 62 women at the time of delivery. Expression of 14 placental genes associated with cholesterol packaging and transfer was assessed in rodent and human samples by quantitative real time polymerase chain reaction. In rats, placental mRNA expression of ApoA2, ApoC2, Cubn, Fgg, Mttp and Ttr was significantly elevated (3–30 fold) in animals fed a high LA (36% fat) diet, suggesting increased cholesterol transport across the placenta in this group. In women, maternal BMI was associated with fewer inconsistent alterations in gene expression. In summary, sub-optimal maternal nutrition is associated with alterations in the expression of genes associated with cholesterol transport in a rat model. This may contribute to altered fetal development and potentially programme disease risk in later life. Further investigation of human placenta in response to specific dietary interventions is required.
We investigated whether changes in nutrient availability affected N, P, S and polyphenol concentrations in different leaf-development stages of three brevideciduous and three evergreen dominant woody species in a nutrient-limited savanna woodland in Central Brazil. Treatments included eight years of annual fertilization with 100 kg ha−1 of N, P, N plus P and control, each replicated in four randomized 15 × 15-m plots. All species increased S concentrations (minimum 28%) in young and mature leaves in fertilized plots. Dalbergia miscolobium decreased total phenol concentrations with P (−34.3%, −23.7%) and NP fertilization (−28.2%, −17.1%). Blepharocalyx salicifolius increased total phenol (27.6%, 18.8%) and tannin (46.3%; 43.5%) in P fertilized and increased total phenol (33.9%) and tannin (27.8%, 43.5%) in NP fertilized plots. Total phenol concentration decreased with leaf age in Ouratea hexasperma, Styrax ferrugineus and Blepharocalyx salicifolius, which also decreased tannin concentration with leaf age. For all treatments, brevideciduous species had higher N, P, total phenols and tannin concentrations and lower S concentration than evergreens. These differences between phenological groups suggest that tropical ecosystems responses to environmental changes are more complex than anticipated by global vegetation models, with consequences for predictions in ecosystem functions and resilience.
The paper presents the design and experimental testing of the control system used in a new morphing wing application with a full-scaled portion of a real wing. The morphing actuation system uses four similar miniature brushless DC (BLDC) motors placed inside the wing, which execute a direct actuation of the flexible upper surface of the wing made from composite materials. The control system of each actuator uses three control loops (current, speed and position) characterised by five control gains. To tune the control gains, the Particle Swarm Optimisation (PSO) method is used. The application of the PSO method supposed the development of a MATLAB/Simulink® software model for the controlled actuator, which worked together with a software sub-routine implementing the PSO algorithm to find the best values for the five control gains that minimise the cost function. Once the best values of the control gains are established, the software model of the controlled actuator is numerically simulated in order to evaluate the quality of the obtained control system. Finally, the designed control system is experimentally validated in bench tests and wind-tunnel tests for all four miniature actuators integrated in the morphing wing experimental model. The wind-tunnel testing treats the system as a whole and includes, besides the evaluation of the controlled actuation system, the testing of the integrated morphing wing experimental model and the evaluation of the aerodynamic benefits brought by the morphing technology on this project. From this last perspective, the airflow on the morphing upper surface of the experimental model is monitored by using various techniques based on pressure data collection with Kulite pressure sensors or on infrared thermography camera visualisations.
The scholarship on political skill documents that it is a social savvy, personal style construct, associated with positive personal and organizational outcomes. However, this study takes a counterintuitive view and demonstrates that despite being a positive resource, political skill also has the potential to be used as a self-serving device to achieve one's personal agendas in the form of self-serving counterproductive work behaviors. Borrowing insights from the trait activation theory, this study demonstrates that a context, high in political perceptions, acts as an incentivized condition for politically skilled people to execute its dark side. The results supported the hypothesis and revealed that under high perceptions of organizational politics, political skill will have a significant, positive relation with self-serving counterproductive work behaviors. The study discusses important theoretical and practical implications of these results and extends the domains of political skill and counterproductive work behaviors.
In the present work, mechanical, tribological, and electrochemical behaviors of Al Alloy 6061–(0–10) % B4C–(0.25–1.2) % graphene nanoplatelets (GNPs) composites, prepared by a combination of solution mixing and powder metallurgy, were investigated. Properties such as hardness, compressive strength, wear rates, and coefficient of friction (COF) were used to investigate the effects of GNPs on mechanical and self-lubricating tribological behavior. The corrosion resistance of composites was investigated using potentiodynamic polarization and electrochemical impedance techniques. Scanning electron microscopy, energy-dispersive X-ray spectroscopy (EDS), and EDS mapping were employed to study the distribution, the fracture profile, and wear mechanism. The AA 6061–10% B4C–0.6% GNPs composites exhibited sharp increase in hardness and compressive strength and significant decrease in wear rates and COF. However, for GNPs contents exceeding over 0.6 wt%, mechanical properties and wear performances deteriorated. Pulling out of sheared pultruded GNPs was observed during the fracture of composites. Worn surfaces of GNPs-containing composites showed the smeared graphene layer with some macro-cracks exhibiting delamination wear. It was found that the corrosion inhibition efficiency of GNPs was more pronounced in H3BO3 environment than in NaCl solution.
S. Akbar Zaidi (2014) advocates a need for a critical reappraisal of the most influential works of Hamza Alavi on the postcolonial state of Pakistan. Alavi is significant because most of the critical political economic literature on Pakistan can trace back its roots from the original works of Alavi (Zaidi 2014:48). To understand Alavi's work, it is necessary to be cognizant of the following three broad conjectures: the historical legacy of colonialism, internal class formations of the postcolonial society and the relationship of the postcolonial state with the external world (core countries of the Global North). This chapter primarily focuses on the first two conjectures.
This chapter builds on recent scholarship (see Akhtar 2018; Zaidi 2014) and presents a new understanding of the postcolonial state-society in Pakistan by drawing from Lefebvre's (2009) work on state-spatiality and the Marxian circuit of capital framework. It is argued in this chapter that the postcolonial state of Pakistan can be best characterised by uneven state spatiality. The dynamics of state-spatiality have been largely overlooked in the existing literature2 on postcolonial Pakistan. It is time to draw from this rich strand of literature to delineate the inherent contradictions of the postcolonial state and society of Pakistan. Zaidi (2014) marks a major departure from Alavi's class formulation by arguing that institutions are more significant as compared to class in understanding dynamics of postcolonial Pakistan. This chapter adds to the class versus institutions debate by using the Marxian circuit of capital framework. It is argued here that both class and institutions are dialectically interlinked and they mutually co-determine the underlying political economic dynamics of postcolonial capitalism in Pakistan.
The rest of this chapter is structured as follows. The second section introduces the processual concept of the state. The third section presents the notion of state spatiality and socio-spatial dialectic and the next section juxtaposes the concept of processual state and state-spatiality in the context of the postcolonial state of Pakistan. In the fifth section, the political economy of informalisation in Pakistan is discussed in the context of the heterogeneity and fractured nature of the postcolonial state. The sixth section discusses the importance of using the Marxian circuit of capital framework to conceptualise the political economic processes as a dialectical interplay of class and institution in the context of the postcolonial state of Pakistan. The final section provides a conclusion to the chapter.
The environmental and economic realities of Arctic climate change present novel problems for international law. Arctic warming and pollution raise important questions about responsibilities and accountabilities across borders, as they result from anthropogenic activities both within and outside the Arctic region, from the Global North and the Global South. Environmental interdependencies and economic development prospects connect in a nexus of risk and opportunity that raises difficult normative questions pertaining to Arctic governance and sovereignty. This article looks at how the Arctic has been produced in international legal spaces. It addresses the implication of states and Indigenous peoples in processes of Arctic governance. Looking at specific international legal instruments relevant to Arctic climate change and development, the author attempts to tease out the relationship between the concepts of Indigenous rights and state sovereignty that underlie these international legal realms. What do these international legal regimes tell us with respect to the role of Arctic Indigenous peoples and the role of states in governing the ‘global’ Arctic? It is argued that while international law has come a long way in recognizing the special status of Indigenous peoples in the international system, it still hesitates to recognize Indigenous groups as international law makers. Comparing the status of Indigenous peoples under specific international regimes to their role within the Arctic Council, it becomes evident that more participatory forms of global governance are entirely possible and long overdue.
Projections of a burgeoning population coupled with global environmental change offer an increasingly dire picture of the state of the world's food security in the not-too-distant future. But how can we transform the current food system to become more sustainable, more equitable and more just? We identify kitchens as sites of transformative innovation in the food system where cooks and chefs can leverage traditional food knowledge about local food species to create delicious and nutritious dishes. Achieving a sustainable food system is a grand challenge, one where cooks in particular are stepping forward as innovators to find solutions.
Identification of influential nodes is an important step in understanding and controlling the dynamics of information, traffic, and spreading processes in networks. As a result, a number of centrality measures have been proposed and used across different application domains. At the heart of many of these measures lies an assumption describing the manner in which traffic (of information, social actors, particles, etc.) flows through the network. For example, some measures only count shortest paths while others consider random walks. This paper considers a spreading process in which a resource necessary for transit is partially consumed along the way while being refilled at special nodes on the network. Examples include fuel consumption of vehicles together with refueling stations, information loss during dissemination with error-correcting nodes, and consumption of ammunition of military troops while moving. We propose generalizations of the well-known measures of betweenness, random-walk betweenness, and Katz centralities to take such a spreading process with consumable resources into account. In order to validate the results, experiments on real-world networks are carried out by developing simulations based on well-known models such as Susceptible-Infected-Recovered and congestion with respect to particle hopping from vehicular flow theory. The simulation-based models are shown to be highly correlated with the proposed centrality measures.
As image analysis expands into clinical and basic applications it is important that users be aware of opportunities and limitations. A common image analysis workflow involves the digitization of stained tissue sections into a red-green-blue (RGB) colour model for quantitative interpretation. Upstream of the digital image, quality and variability can be degraded at each step (tissue handling, fixation, sectioning, staining, image acquisition). Digital image analysis presents additional steps where variables can affect data quality. Image analysis platforms are not uniform. Aside from interface preferences, some introduce unintended variability due to their processing architecture that may not be obvious to the end-user. One important component of this is colour space representation: hue-saturation-intensity (HSI) vs. colour deconvolution (CD). A potential weakness of analyses within the HSI colour space is the mis-identification of darkly stained pixels, particularly when more than one stain is present. We were interested to discover whether HSI or CD provided greater fidelity in a typical immunoperoxidase/hematoxylin dataset.
Fifty-nine samples were processed using HSI- and CD-based analyses. Processed image pairs were compared with the original sample to determine which processed image provided a more accurate representation. CD proved superior to HSI in 94.9% of the analyzed image pairs. Where the option exists, CD-based image analysis is strongly recommended.
This presentation will enable the learner to:
1.To describe differences between HSI and CD colour spaces
2.To explain limitations in the use of HSI-based analyses
3.To be aware of recent developments in CD-based platforms
As many as 70% of intensive care unit (ICU) survivors suffer from long-term physical, cognitive, and psychological impairments known as post-intensive care syndrome (PICS). We describe how the first ICU survivor clinic in the United States, the Critical Care Recovery Center (CCRC), was designed to address PICS using the principles of Agile Implementation (AI).
The CCRC was designed using an eight-step process known as the AI Science Playbook. Patients who required mechanical ventilation or were delirious ≥48 hours during their ICU stay were enrolled in the CCRC. One hundred twenty subjects who completed baseline HABC-M CG assessments and had demographics collected were included in the analysis to identify baseline characteristics that correlated with higher HABC-M CG scores. A subset of patients and caregivers also participated in focus group interviews to describe their perceptions of PICS.
Quantitative analyses showed that the cognitive impairment was a major concern of caregivers. Focus group data also confirmed that caregivers of ICU survivors (n = 8) were more likely to perceive cognitive and mental health symptoms than ICU survivors (n = 10). Caregivers also described a need for ongoing psychoeducation about PICS, particularly cognitive and mental health symptoms, and for ongoing support from other caregivers with similar experiences.
Our study demonstrated how the AI Science Playbook was used to build the first ICU survivor clinic in the United States. Caregivers of ICU survivors continue to struggle with PICS, particularly cognitive impairment, months to years after discharge. Future studies will need to examine whether the CCRC model of care can be adapted to other complex patient populations seen by health-care professionals.
Refugees are confronted with the task of adapting to the long-term erosion of psychosocial systems and institutions that in stable societies support psychological well-being and mental health. We provide an overview of the theoretical principles and practical steps taken to develop a novel psychotherapeutic approach, Integrative Adapt Therapy (IAT), which aims to assist refugees to adapt to these changes. This paper offers the background informing ongoing trials of IAT amongst refugees from Myanmar.
A systematic process was followed in formulating the therapy and devising a treatment manual consistent with the principles of the Adaptation and Development After Persecution and Trauma (ADAPT) model. The process of development and refinement was based on qualitative research amongst 70 refugees (ten from West Papua and 60 Rohingya from Myanmar). The therapeutic process was then piloted by trained interventionists amongst a purposively selected sample of 20 Rohingya refugees in Malaysia.
The final formulation of IAT represented an integration of the principles of the ADAPT model and evidence-based techniques of modern therapies in the field, including a transdiagnostic approach and the selective use of cognitive behavioural treatment elements such as problem-solving and emotional regulation techniques. The steps outlined in refining the manual are outlined in relation to work amongst West Papuan refugees, and the process of cultural and contextual modifications described during early piloting with Rohingya refugees in Malaysia.
IAT integrates universal principles of the ADAPT model with the particularities of the culture, history of conflict and living context of each refugee community; this synthesis of knowledge forms the basis for participants gaining insights into their personal patterns of psychosocial adaptation to the refugee experience. Participants then apply evidence-based techniques to improve their capacity to adapt to the serial psychosocial changes they have encountered in their lives as refugees. The overarching goal of IAT is to provide refugees with a coherent framework that assists in making sense of their experiences and their emotional and interpersonal reactions to the challenges they confront within the family and community context. As such, the principles of a general model (ADAPT) are used as a springboard for making concrete, manageable and meaningful life changes at the individual level, a potentially novel approach for psychosocial interventions in the field.
An improved understanding of diagnostic and treatment practices for patients with rare primary mitochondrial disorders can support benchmarking against guidelines and establish priorities for evaluative research. We aimed to describe physician care for patients with mitochondrial diseases in Canada, including variation in care.
We conducted a cross-sectional survey of Canadian physicians involved in the diagnosis and/or ongoing care of patients with mitochondrial diseases. We used snowball sampling to identify potentially eligible participants, who were contacted by mail up to five times and invited to complete a questionnaire by mail or internet. The questionnaire addressed: personal experience in providing care for mitochondrial disorders; diagnostic and treatment practices; challenges in accessing tests or treatments; and views regarding research priorities.
We received 58 survey responses (52% response rate). Most respondents (83%) reported spending 20% or less of their clinical practice time caring for patients with mitochondrial disorders. We identified important variation in diagnostic care, although assessments frequently reported as diagnostically helpful (e.g., brain magnetic resonance imaging, MRI/MR spectroscopy) were also recommended in published guidelines. Approximately half (49%) of participants would recommend “mitochondrial cocktails” for all or most patients, but we identified variation in responses regarding specific vitamins and cofactors. A majority of physicians recommended studies on the development of effective therapies as the top research priority.
While Canadian physicians’ views about diagnostic care and disease management are aligned with published recommendations, important variations in care reflect persistent areas of uncertainty and a need for empirical evidence to support and update standard protocols.