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Written in a conversational tone, this classroom-tested text introduces the fundamentals of linear programming and game theory, showing readers how to apply serious mathematics to practical real-life questions by modelling linear optimization problems and strategic games. The treatment of linear programming includes two distinct graphical methods. The game theory chapters include a novel proof of the minimax theorem for 2x2 zero-sum games. In addition to zero-sum games, the text presents variable-sum games, ordinal games, and n-player games as the natural result of relaxing or modifying the assumptions of zero-sum games. All concepts and techniques are derived from motivating examples, building in complexity, which encourages students to think creatively and leads them to understand how the mathematics is applied. With no prerequisite besides high school algebra, the text will be useful to motivated high school students and undergraduates studying business, economics, mathematics, and the social sciences.
Tenecteplase is a thrombolytic protein drug used by paramedics, emergency responders, and critical care medical personnel for the prehospital treatment of blood clotting diseases. Minimizing the time between symptom onset and the initiation of thrombolytic treatment is important for reducing mortality and improving patient outcomes. However, the structure of protein drug molecules makes them susceptible to physical and chemical degradation that could potentially result in considerable adverse effects. In locations that experience extreme temperatures, lyophilized tenecteplase transported in emergency service vehicles (ESVs) may be subjected to conditions that exceed the manufacturer’s recommendations, particularly when access to the ambulance station is limited.
This study evaluated the impact of heat exposure (based on temperatures experienced in an emergency vehicle during summer in a regional Australian city) on the stability and efficacy of lyophilized tenecteplase.
Vials containing 50mg lyophilized tenecteplase were stored at 4.0°C (39.2°F), 35.5°C (95.9°F), or 44.9°C (112.8°F) for a continuous period of eight hours prior to reconstitution. Stability and efficacy were determined through assessment of: optical clarity and pH; analyte concentration using UV spectrometry; percent protein monomer and single chain protein using size-exclusion chromatography; and in vitro bioactivity using whole blood clot weight and fibrin degradation product (D-dimer) development.
Heat treatment, particularly at 44.9°C, was found to have the greatest impact on tenecteplase solubility; the amount of protein monomer and single chain protein lost (suggesting structural vulnerability); and the capacity for clot lysis in the form of decreased D-dimer production. Meanwhile, storage at 4.0°C preserved tenecteplase stability and in vitro bioactivity.
The findings indicate that, in its lyophilized form, even relatively short exposure to high temperature can negatively affect tenecteplase stability and pharmacological efficacy. It is therefore important that measures are implemented to ensure the storage temperature is kept below 30.0°C (86.0°F), as recommended by manufacturers, and that repeated refrigeration-heat cycling is avoided. This will ensure drug administration provides more replicable thrombolysis upon reaching critical care facilities.
This report presents the latest data from ongoing excavations at Jebel Moya, Sudan. This year saw the opening of five new trenches and continued excavation of an archaeologically rich trench. We have recovered four individual burials, a mud brick wall and a number of animal and archaeobotanical remains. The excavations also yielded a longer pottery sequence, showing clearly that the site was in use by at least the sixth millennium BC. This season confirms the long and complex history of Jebel Moya and provides the material for future studies on population health and subsistence. This season also saw an increase in community engagement and a more detailed study of the various historical trajectories that make up the biography of Jebel Moya.
The V&A is home to a painted crucifix that has been attributed to the Sicilian master, Antonio de Saliba (c 1466/7–c 1535), who was active in Venice and eastern Sicily during the Renaissance. This paper takes a fresh look at the documentary sources that were published before the devastating earthquake that struck Messina, in the north west of Sicily, in 1908. In re-examining these sources, this paper reveals new insights into Antonio de Saliba’s oeuvre and enables a possible identification of the V&A’s painted crucifix with a specific contractual agreement that links this crucifix’s commission to the artist – specifically with a commission de Saliba received in 1508 from Limina, a small town in the province of Messina. The roots of this provincial commission would explain the persistence of a retardataire production visible in this early sixteenth-century painted crucifix. This paper also challenges the preconceived idea that such painted crucifixes were destined to be displayed high up in a church, on a tramezzo or beam.
Behavioral and psychological symptoms of dementia (BPSD), constitute a major clinical component of Alzheimer’s disease (AD). There is a growing interest in BPSD as they are responsible for a large share of the suffering of patients and caregivers, and they strongly determine the patient’s lifestyle and management. Better detection and understanding of these symptoms is essential to provide appropriate management. This article is a consensus produced by the behavioral group of the European Alzheimer’s Disease Consortium (EADC). The aim of this article is to present clinical description and biological correlates of the major behavioral and psychological symptomatology in AD. BPSD is not a unitary concept. Instead, it should be divided into several symptoms or more likely: groups of symptoms, each possibly reflecting a different prevalence, course over time, biological correlate and psychosocial determinants. There is some clinical evidence for clusters within groups of BPSD. Biological studies indicate that patients with AD and BPSD are associated with variations in the pathological features (atrophy, brain perfusion/metabolism, histopathology) when compared to people with AD without BPSD. An individually tailored approach taking all these aspects into account is warranted as it may offer more, and better, pharmacological and non-pharmacological treatment opportunities.
The Sudan occupies a fairly complex place in archaeological enquiry. This is not a result of the archaeological record, rather it is due to a particular perception of the Sudan, its archaeology and history. The first excavators were archaeologists and anatomists who either worked in Egypt or in the Mediterranean, while the Anglo-Egyptian Condominium encouraged white-only scholars to both conduct research and to be active members of the newly formed political service in order to ‘know the natives’. In other words, archaeology from the outset was intimately connected to a particular political narrative and aim. This paper traces the historical context from the early 20th century to the development of archaeology south of beyond the Sixth Cataract south of the present-day capital of Khartoum, showing how it was created by Henry Wellcome. In particular, it focuses on the vast mortuary and habitation site of Jebel Moya, south-central Sudan, where new fieldwork is yielding fruitful results. Henry Wellcome's contribution to archaeology remains under-acknowledged. This long-overdue critical assessment traces and contextualizes the historical trajectories at play and situates them within the broader historical archaeology context.
There is wide acknowledgement that apathy is an important behavioural syndrome in Alzheimer’s disease and in various neuropsychiatric disorders. In light of recent research and the renewed interest in the correlates and impacts of apathy, and in its treatments, it is important to develop criteria for apathy that will be widely accepted, have clear operational steps, and that will be easily applied in practice and research settings. Meeting these needs is the focus of the task force work reported here.
The task force includes members of the Association Française de Psychiatrie Biologique, the European Psychiatric Association, the European Alzheimer’s Disease Consortium and experts from Europe, Australia and North America. An advanced draft was discussed at the consensus meeting (during the EPA conference in April 7th 2008) and a final agreement reached concerning operational definitions and hierarchy of the criteria.
Apathy is defined as a disorder of motivation that persists over time and should meet the following requirements. Firstly, the core feature of apathy, diminished motivation, must be present for at least four weeks; secondly two of the three dimensions of apathy (reduced goal-directed behaviour, goal-directed cognitive activity, and emotions) must also be present; thirdly there should be identifiable functional impairments attributable to the apathy. Finally, exclusion criteria are specified to exclude symptoms and states that mimic apathy.
The physical aspect of Maltese patients treated with antipsychotics
Patients with mental health problems are known to have more physical comorbidities resulting in reduced life expectancy when compared to the general population. The NICE guidelines (2014) has directed clinicians to monitor the physical health of patients with psychosis.
This study sets to determine whether management of physical health comorbidities of Maltese patients treated with antipsychotics is optimal.
The aim of this study is to screen for risk factors of poor physical health, features of the metabolic syndrome and other physical comorbidities amongst Maltese patients treated with antipsychotics.
Patients treated with antipsychotics were randomly enrolled in the study. Parameters measured included weight and waist circumference. Blood pressure and blood glucose monitoring was reviewed. Lipid profiles were checked for dyslipidaemia. Patients were questioned about physical comorbidities (particularly diabetes, cardiovascular diseases and respiratory problems), their smoking status, diet and level of physical activity.
Preliminary results indicate that the physical health of patients treated with antipsychotics in Malta is suboptimal and may be improved.
Patients treated with antipsychotics in Malta need better identification and management of their poor lifestyle choices and physical comorbidities. Simple interventions such as offering suitable advice, education and referring to appropriate specialists to treat identified physical problems may greatly improve patient's quality of life.
The intricate connection between the mind and the body is reflected in the complex relationship between mental and physical health. Previous studies have shown that there may be a link between obesity and poor mental health, with depression in particular. This is more of a concern in Malta since the mean population body mass index (BMI) lies on the upper end of the spectrum.
To examine the association between mental health and obesity in a sampled Maltese population.
To screen for mental health problems and determine the prevalence of somatoform, depression, anxiety, eating disorders and alcohol labuse in various categories of BMI.
A random sample of Maltese people were recruited from various settings including health centres and the general hospital. A questionnaire was carried out for participants who agreed to participate. Their BMI and several risk factors for physical comorbidities were recorded. The ‘PatientHealth Questionnaire’ was then used to screen for the mental health conditions listed in the aims section.
Preliminary results indicate that an increasing BMI is linked to a poorer mental health.
The association between poor mental health andobesity in the sampled Maltese population is of concern since Malta is one ofthe leading countries with the highest prevalence of obesity. Better mental health may be promoted by targeting to achieve a healthier BMI in the local population.
The development of treatment-resistant schizophrenia in a 16-year-old Maltese girl was analyzed in terms of its biopsychosocial model of disease.
To highlight the presentation of treatment-resistant schizophrenia.
To investigate the etiology of treatment-resistant schizophrenia.
To utilize the biopsychosocial model of disease in order to investigate the aetiology of treatment-resistant schizophrenia.
To highlight the treatment modalities utilized in this case of treatment-resistant schizophrenia.
Interviewing the patient.
Analyzing all investigations and documentation made during her admission in an acute psychiatric hospital.
Evaluating the response to various treatment modalities.
Carrying out literature reviews.
Although the aetiology of treatment-resistant schizophrenia remains somewhat unclear even after many years of study, the biopsychosocial model is nevertheless useful in understanding the development of this condition. The treatment modalities to which the patient was resistant were also identified.
Figure not available.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
– loss of control, as shown by unsuccessful efforts to stop the behaviour;
– continuation of the behaviour despite adverse consequences – such as marriage breakdown;
– an obsession with obtaining, using or recovering from the behaviour.
To date, DSM-5 does not recognize sex addiction as a disorder, however when problematic sexual behaviours fulfil these same three criteria, the process is considered to be an addiction.
This case report describes the development of problematic addictive sexual behaviour, possibly as a result of other psychiatric comorbidities including obsessive-compulsive disorder (OCD), alvinophilia, and obsessional fetishism. The presence of the Madonna-Puttana syndrome is also explored.
To use the biopsychosocial model to investigate the aetiology of addictive problematic sexual behaviour. To explore the role of psychiatric comorbidities in the expression of such behaviour. To examine the holistic impact of sexual addictions. To examine the treatment modalities of addictive problematic sexual behaviour.
A 25 year old happily-married nurse who confessed to serial extramarital affairs was interviewed. Underlying psychiatric comorbidities were identified. Family members were also interviewed for a collateral history. The above objectives were explored and the response to various treatment modalities were evaluated. Literature reviews were carried out.
This case illustrates a form of OCD which manifested as addictive problematic sexual behaviour. The message portrayed is that hope exists for such couples once various treatment modalities are put into action.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
This paper tests whether in a PAYG system there is an inter-generational balance between the contributions made during the working-career and the pension benefit received in retirement; covering different cohorts. The analysis takes Malta as a case study. Though the dependency ratio is comparatively low, the population is rapidly ageing. The results show that there is a generational imbalance with the young cohort unlikely to be any better off than those who have already retired. This however is sensitive to the assumed discount rate and the ‘no policy’ change scenario. The results also show that future generations may be net-gainers assuming a sustained level of wage growth. If, on the other hand, wage growth slows, the younger generation may become increasingly reliant on the bequests of older generations. This would explain why pressure has increased to regularly adjust the existing PAYG system as well to introduce other forms of pension schemes.
Introduction: By virtue of the nature of their work, emergency medicine physicians and residents experience high cognitive load and stress, which are known to affect physician performance and patient outcomes. However, the contribution of cognitive load has not previously been measured during the clinical work of emergency physicians. The objectives of this study were to measure cognitive load and stress in emergency physicians and residents during clinical work, evaluate the relative contribution of multiple factors on cognitive load, and to determine the effect of experience on these results. Methods: This observational study was conducted at an academic Canadian Urgent Care Centre from July to August 2018. Emergency medicine residents and staff physicians completed a survey while on shift to evaluate measures of cognitive load and acute stress. Patient acuity and the number of active patients for each physician, hours worked and patients in the waiting room were recorded. Correlational analyses and multivariable linear regression were performed to evaluate the effect of each predictor on measures of overall cognitive load. Results: A total of 131 questionnaires were completed by 42 physicians (87 questionnaires from 26 staff physicians and 44 questionnaires from 16 residents). Results showed that staff physicians carried a significantly higher patient load compared to residents (p < 0.001). There were no differences in mean overall cognitive load (p = 0.25), acute stress (p = 0.17) or measured subcomponents of cognitive load between the two groups. Perceived case difficulty and acute stress were strong predictors of overall cognitive load, while level of distraction did not correlate with the other outcomes. The number of patients in the waiting room predicted acute stress in staff physicians, while the number of higher acuity patients was a significant predictor in residents. Conclusion: Measures of overall cognitive load and acute stress were strongly correlated in the clinical setting. Different factors affect cognitive load and acute stress in staff physicians compared to residents. Appreciating these differences may help medical educators understand the cognitive challenges faced by learners in a clinical context, and aid in the design of cognitive and educational strategies to help mitigate these challenges and reduce stress.
To study potentially modifiable factors associated with the severity of agitation or aggression (A/A) symptoms among Alzheimer’s disease (AD) patients.
Data from the Impact of Cholinergic Treatment Use (ICTUS) study, European longitudinal prospective observational study.
Community dwelling outpatients included in 29 European memory clinics.
1375 participants with probable AD (Mini-Mental State Examination score of 10–26) with an informal caregiver.
At baseline and twice yearly over the two-year follow-up, patients underwent comprehensive clinical and neuropsychological assessments: sociodemographic data, cognitive status, functional impairment, and assessment of neuropsychiatric symptoms based on Neuro-Psychiatric Inventory (NPI). The ZARIT scale assessed the caregiver’s burden. The variable of interest was the severity of the item of A/A of the NPI. To study factors associated to the severity of A/A symptoms six months later, a multivariate mixed regression model was used.
Frequency of A/A symptom varied from 30% to 34% at each visit. Two factors were found to be independently associated with the severity of A/A: (1) the presence of affective disorder (anxiety, depression, and/or irritability) that increased the severity of the A/A by 0.89 point (coefficient:0.89; 95% Confidence Interval (CI) = [0.48,1.30], p < 0.001), and (2) a severe caregiver burden that increased the severity of the A/A by 1.08 point (coefficient:1.08; 95% CI = [0.69,1.47], p < 0.001).
Research should evaluate whether the identification and treatment of an affective disorder along with the evaluation and optimal management of the caregiver would have a positive impact on the course of A/A in mild to moderate AD patients.
To estimate the impact of comorbid diabetes on caregiver stress in Alzheimer's disease (AD) patients from the Impact of Cholinergic Treatment Use (ICTUS) study.
Using the Data from the ICTUS study, diabetes mellitus (DM) was recorded at baseline and caregiver burden was assessed twice per year using the Zarit Burden Interview (ZBI) scale. The three-factorial model of ZBI (the effect on the social and personal life of caregivers, the psychological burden and the feelings of guilt) was adopted. Linear mixed models were used to examine the relation between DM and the scores of ZBI.
The present analyses were conducted on 1,264 AD subjects. A total of 156 patients (12.3%) had DM with taking antidiabetic medication and/or self-report of a history. At baseline, the caregivers of patients with or without DM had similar ZBI global scores and similar scores of three different factors of ZBI. Unadjusted and adjusted models both indicated that ZBI global score increased over a 24-month follow-up without significant effect of DM. Similarly, unadjusted model showed that DM was not determining any significant difference in the score of any factor. However, adjusted model indicated that in diabetic patients, the scores of the social and personal life of caregivers and the psychological burden increased more slowly than those in non-diabetic patients (p = 0.04 and 0.01, respectively).
DM may affect the caregivers’ daily social and personal life and psychological burden in AD patients. It is necessary for further research.