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Anxiety disorders are among the most prevalent psychiatric conditions. Despite many proven pharmacological and non-pharmacological treatments available, high rates of partial response and low rates of long-term remission remain. Ketamine has been receiving increasing attention as an interventional treatment modality in psychiatry, especially among refractory conditions, including major depressive disorder. There is limited yet growing evidence to support the use of ketamine in anxiety disorders. In this review of the literature, we present case reports, case series, and controlled trials demonstrating proof-of-concept for its potential role in the treatment of anxiety and anxiety spectrum disorders. Its unique mechanism of action, rapid onset, and high rate of response have driven its use in clinical practice. Ketamine is generally well tolerated by patients and has a limited side effect profile; however, the effects of long-term use are unknown. While there is a growing body of research and increasing clinical experience to suggest ketamine may have clinical applications in the treatment of refractory anxiety disorders, further research to determine long-term safety and tolerability is indicated.
One of the strongest impulses that led to the creation of the Organization of African Unity (OAU) in 1963 was the desire of free Africa to hasten independence in colonized Africa. When the leaders of independent Africa convened to inaugurate the first international regional organization of its kind in Africa, there seemed total agreement on the principle of self-determination. What Kwame Nkrumah had proclaimed six years earlier upon Ghana's accession to independence was echoed in the keynote address of the Ethiopian Emperor: “Our liberty is meaningless unless all Africans are free. Our brothers in the Rhodesias … Mozambique … cry out in anguish for our support and assistance.”
We have automated a Seeman-Bohlin Guinier x-ray diffractometer by interfacing it to a minimally configured PDP 11/23 computer. The programs that run on the microcomputer to control the operation of the diffractometer are stored on a mainframe host running the UNIX+ operating system. A software interface allows a particular data acquisition program to be downloaded from the UNIX host and executed on the satellite processor. This same interface allows the collected data to be periodically off-loaded to the host for processing and storage.
To systematically review studies from Irish prisons that estimate the prevalence of major mental illness, alcohol and substance misuse, and homelessness at the time of committal.
Healthcare databases were searched for studies quantifying the point prevalence for each outcome of interest. Searches were augmented by scanning of bibliographies and searches of governmental and non-governmental websites. Proportional meta-analyses were completed for each outcome.
We found eight, six and five studies quantifying the point prevalence of major mental illness, substance misuse, and homelessness respectively. Considerable heterogeneity was found for each subgroup (except psychosis where substantial heterogeneity was observed) and random effects models were used to calculate pooled percentages. The pooled percentage for psychotic disorder was 3.6% [95% confidence interval (CI) 3.0–4.2%], for affective disorder 4.3% (95% CI 2.1–7.1%), for alcohol use disorder 28.3% (95% CI 19.9–37.4%), for substance use disorder 50.9% (95% CI 37.6–64.2%) and for those who were homeless on committal 17.4% (95% CI 8.7–28.4%).
Estimates for the prevalence of psychotic illness and substance abuse amongst Irish prisoners are in keeping with international estimates of morbidity in prisons, whilst those for affective disorders are lower. The prevalence of homelessness in committal to Irish prisons is higher than some international estimates. Rates for psychoses, alcohol and substance misuse as well as homelessness in Irish prisons are significantly higher than the general population prevalence of these vulnerabilities. A need for service development is discussed.
Introduction: Interest groups have become increasingly popular as students explore potential career paths earlier in their undergraduate experience. Emergency medicine (EM) has grown as a specialty and the match has become quite competitive. Attractive features of EM cited by learners (diversity, procedural skills and flexible schedule) appeal broadly to the undergraduate population. Learners at Memorial University recognized this leadership opportunity and worked with faculty to reach this wide target audience through a streamlined iterative evaluation of their EM Interest Group (EMIG). Methods: The local EMIG was formed in 2010. Yearly, EMIG executive work with outgoing members using prior experiences, contacts and best practices to facilitate handover and progress. From 2015 to present, 305 surveys were collected, giving an 81.9% response rate. 59.7% of respondents were first year students, and 40.3% were second year. The survey consisted of Likert scale and open-response questions. The Likert scale questions yielded favorable responses. 304 students (99.6%) felt presenters were knowledgeable, 301 (98.6%) would recommend the sessions to others and 301 (98.6%) were satisfied they attended. Surprisingly, 133 students (43.6%) said they were not interested in Emergency Medicine, likely attending due to the appeal of session topics and transferrable of EM skills. 232 (76.0%) stated that attendance did increase their interest in EM. Top responses for aspects of EM most interesting to them included: ability to find a work/life balance, ability to work urban or rural, variety of cases seen, and the non-routine shifts. Results: Survey feedback is used to inform refinement of the content, delivery and format of EMIG activities, delivered by EM faculty. Hands-on sessions (eg. suturing & airway management) have been popular. Informational sessions, on specific medical topics (ECG, resuscitation cases) or broader topics (EM streams) have also been very well received. Inclusion of all interested students, particularly large numbers for hands-on sessions, has presented challenges. Beyond current survey results, it will be interesting to consider if EMIG participation translates to learning or behavioral changes relevant to later clinical encounters; a question that will be difficult to quantify. Conclusion: The EM interest group is one of the most active at Memorial University. Survey results indicate that participants enjoy the EMIG session content and the structured iterative approach used by the group has been successful in maintaining an effective student led organization.
Non-axisymmetric endwalls in turbine stages have shown to be a robust method to improve the performance of turbines in both power generation and aero-derivative applications. Non-axisymmetric endwalls target the control of secondary flows and are designed using detailed computational fluid dynamics coupled with a variety of optimisation algorithms and utilising a number of objective functions according to the engine company or researcher's preference. These numerical predictions are often backed up by detailed measurements in linear and annular cascades and later proven in full-scale engine tests. Relatively little literature is available describing their performance in rotating test rigs or at conditions other than design, apart from that of the authors. This study comprehensively revisits the low-speed, model turbines used in the earlier study, replacing all of the 5-hole probe data with more accurate results and additional hot-film measurements. These results together with computational fluid dynamics solutions are used to show the success of the method across a large incidence range and to compare to earlier cascade results for a similar endwall and blade profile to establish the usefulness of cascade testing in this application. In addition, a comparison to two other off-design studies is made. Results indicate that the endwalls successfully improve the rotor total isentropic efficiency at all test conditions and that the improvement increases with increased turning in the blade row, from 0.5% to 1.8% across the incidence range. The results also compare well to the estimation of isentropic efficiency improvement that can be drawn from the cascade testing which stands at 1.55%.
Hunger strikes in a custodial setting are complex to manage clinically, with associated legal and ethical complexities. Hunger strikes in Irish prisons have received, and are likely to continue to be the focus of, considerable media attention. Whilst there is an internationally accepted consensus ethical position, there is limited legal guidance available for psychiatrists to draw upon in such cases. In this paper, we review recent case-law and discuss the legal considerations in the management of prisoners on hunger strike.
The effects of shape and thickness of a tin surface layer and of the energy of a 170 ps neodymium:yttrium-aluminum-garnet laser pulse on the conversion efficiency (CE) into extreme ultraviolet emission in the 13.5 nm region is investigated. Whereas a CE of up to 1.16% into the 2% reflection band of multilayer Mo/Si optics was measured for a bulk Sn target at a laser energy of 25 mJ, significant CE enhancement up to 1.49% is demonstrated for a 200-nm-thick Sn layer on a microstructured porous alumina substrate.
We sought to identify and review published studies that discuss the ethical considerations, from a physician’s perspective, of managing a hunger strike in a prison setting.
A database search was conducted to identify relevant publications. We included case studies, case series, guidelines and review articles published over a 20-year period. Non-English language publications were translated.
The review found 23 papers from 12 jurisdictions published in five languages suitable for inclusion.
Key themes from included publications are identified and summarised in the context of accepted guidelines from the World Medical Association. Whilst there seems to be an overall consensus favouring autonomy over beneficence, tensions along this fine balance are magnified in jurisdictions where legislation leads to a dual loyalty conflict for the physician.
To search for studies on tongue–lip adhesion and tongue repositioning used as isolated treatments for obstructive sleep apnoea in children with Pierre Robin sequence.
A systematic literature search of PubMed/Medline and three additional databases, from inception through to 8 July 2016, was performed by two authors.
Seven studies with 90 patients (59 tongue–lip adhesion and 31 tongue repositioning patients) met the inclusion criteria. Tongue–lip adhesion reduced the mean (± standard deviation) apnoea/hypopnoea index from 30.8 ± 22.3 to 15.4 ± 18.9 events per hour (50 per cent reduction). The apnoea/hypopnoea index mean difference for tongue–lip adhesion was −15.28 events per hour (95 per cent confidence interval = −30.70 to 0.15; p = 0.05). Tongue–lip adhesion improved the lowest oxygen saturation from 75.8 ± 6.8 to 84.4 ± 7.3 per cent. Tongue repositioning reduced the apnoea/hypopnoea index from 46.5 to 17.4 events per hour (62.6 per cent reduction). Tongue repositioning improved the mean oxygen saturation from 90.8 ± 1.2 to 95.0 ± 0.5 per cent.
Tongue–lip adhesion and tongue repositioning can improve apnoea/hypopnoea index and oxygenation parameters in children with Pierre Robin sequence and obstructive sleep apnoea.
With the UK population ageing, deciding upon a satisfactory and sustainable system for the funding of people’s long-term care (LTC) needs has long been a topic of political debate. Phase 1 of the Care Act 2014 (“the Act”) brought in some of the reforms recommended by the Dilnot Commission in 2011. However, the Government announced during 2015 that Phase 2 of “the Act” such as the introduction of a £72,000 cap on Local Authority care costs and a change in the means testing thresholds1 would be deferred until 2020. In addition to this delay, the “freedom and choice” agenda for pensions has come into force. It is therefore timely that the potential market responses to help people pay for their care within the new pensions environment should be considered. In this paper, we analyse whether the proposed reforms meet the policy intention of protecting people from catastrophic care costs, whilst facilitating individual understanding of their potential care funding requirements. In particular, we review a number of financial products and ascertain the extent to which such products might help individuals to fund the LTC costs for which they would be responsible for meeting. We also produce case studies to demonstrate the complexities of the care funding system. Finally, we review the potential impact on incentives for individuals to save for care costs under the proposed new means testing thresholds and compare these with the current thresholds. We conclude that:
∙Although it is still too early to understand exactly how individuals will respond to the pensions freedom and choice agenda, there are a number of financial products that might complement the new flexibilities and help people make provision for care costs.
∙The new care funding system is complex making it difficult for people to understand their potential care costs.
∙The current means testing system causes a disincentive to save. The new means testing thresholds provide a greater level of reward for savers than the existing thresholds and therefore may increase the level of saving for care; however, the new thresholds could still act as a barrier since disincentives still exist.
Conventional bedside tests of visuospatial function such as the clock drawing (CDT) and intersecting pentagons tests (IPT) are subject to considerable inconsistency in their delivery and interpretation. We compared performance on a novel test – the letter and shape drawing (LSD) test – with these conventional tests in hospitalised elderly patients.
The LSD, IPT, CDT and the Montreal Cognitive Assessment (MoCA) were performed in 40 acute elderly medical inpatients at University Hospital Limerick The correlation between these tests was examined as well as the accuracy of the visuospatial tests to identify significant cognitive impairment on the MoCA.
The patients (mean age 81.0±7.71; 21 female) had a median MoCA score of 15.5 (range=1–29). There was a strong, positive correlation between the LSD and both the CDT (r=0.56) and IPT (r=0.71). The correlation between the LSD and MoCA (r=0.91) was greater than for the CDT and IPT (both 0.67). The LSD correlated highly with all MoCA domains (ranging from 0.54 to 0.86) and especially for the domains of orientation (r=0.86), attention (0.81) and visuospatial function (r=0.73). Two or more errors on the LSD identified 90% (26/29) of those patients with MoCA scores of ⩽20, which was substantially higher than for the CDT (59%) and IPT (55%).
The LSD is a novel test of visuospatial function that is brief, readily administered and easily interpreted. Performance correlates strongly with other tests of visuospatial ability, with favourable ability to identify patients with significant impairment of general cognition.
The world-systems perspective was invented for modeling and interpreting the expansion and deepening of the capitalist regional system as it emerged in Europe and incorporated the whole globe over the past 500 years (Wallerstein 1974; Chase-Dunn 1998; Arrighi 1994). The idea of a core/periphery hierarchy composed of “advanced” economically developed and powerful states dominating and exploiting “less developed” peripheral regions has been a central concept in the world-systems perspective. In the last decade the world-systems approach has been extended to the analysis of earlier and smaller intersocietal systems. Andre Gunder Frank and Barry Gills (1994) have argued that the contemporary global political economy is simply a continuation of a 5,000-year-old world system that emerged with the first states in Mesopotamia. Christopher Chase-Dunn and Thomas Hall (1997) have modified the basic world-systems concepts to make them useful for a comparative study of very different kinds of systems. They include very small intergroup networks composed of sedentary foragers, as well as larger systems containing chiefdoms, early states, agrarian empires, and the contemporary global system in their scope of comparison.
Prisoners have an exceptional risk of suicide. Cognitive–behavioural therapy for suicidal behaviour has been shown to offer considerable potential, but has yet to be formally evaluated within prisons. This study investigated the feasibility of delivering and evaluating a novel, manualized cognitive–behavioural suicide prevention (CBSP) therapy for suicidal male prisoners.
A pilot randomized controlled trial of CBSP in addition to treatment as usual (CBSP; n = 31) compared with treatment as usual (TAU; n = 31) alone was conducted in a male prison in England. The primary outcome was self-injurious behaviour occurring within the past 6 months. Secondary outcomes were dimensions of suicidal ideation, psychiatric symptomatology, personality dysfunction and psychological determinants of suicide, including depression and hopelessness. The trial was prospectively registered (number ISRCTN59909209).
Relative to TAU, participants receiving CBSP therapy achieved a significantly greater reduction in suicidal behaviours with a moderate treatment effect [Cohen's d = −0.72, 95% confidence interval −1.71 to 0.09; baseline mean TAU: 1.39 (s.d. = 3.28) v. CBSP: 1.06 (s.d. = 2.10), 6 months mean TAU: 1.48 (s.d. = 3.23) v. CBSP: 0.58 (s.d. = 1.52)]. Significant improvements were achieved on measures of psychiatric symptomatology and personality dysfunction. Improvements on psychological determinants of suicide were non-significant. More than half of the participants in the CBSP group achieved a clinically significant recovery by the end of therapy, compared with a quarter of the TAU group.
The delivery and evaluation of CBSP therapy within a prison is feasible. CBSP therapy offers significant promise in the prevention of prison suicide and an adequately powered randomized controlled trial is warranted.
Species-level diversity and evolution of Palaeosinopa from the Willwood Formation of the Bighorn Basin is reassessed based on substantial new material from the Bighorn, Powder River, and Wind River basins. We recognize three species of Palaeosinopa in the Willwood Formation of the Bighorn Basin: P. lutreola, P. incerta, and P. veterrima. The late Wasatchian species P. didelphoides is not present in the Bighorn Basin. The Willwood species can be differentiated based only on size. P. veterrima is the most common and wide-ranging species and is the most variable in size and morphology: the stratigraphically lowest individuals are smaller, with narrower, more crestiform lower molars; whereas the highest are larger, with wider, more bunodont teeth. Although it could be argued that these represent distinct species, we demonstrate that this morphological evolution occurred as the gradual and mosaic accumulation of features, suggesting in situ anagenetic evolution. The two smaller species are present only low in the section (biochrons Wa0–Wa4) and show no discernable evolution in size or morphology. A new skeleton of Palaeosinopa veterrima from the Willwood Formation is described, and other new postcrania are reported. The skeleton is the oldest associated skeleton of Palaeosinopa known, yet it is remarkably similar to those of younger, more derived pantolestids, the primary disparities being minor differences in proportions of the innominate, femur, and tibia, and co-ossification of the distal tibia and fibula. Either P. incerta or P. lutreola was likely the ancestral population that gave rise to the other Wasatchian Palaeosinopa. Alternatively, P. veterrima may have migrated into the Bighorn Basin from the Powder River Basin.
With prevention and treatment of mental disorders a challenge for primary care and increasing capability of electronic medical records (EMRs) to facilitate research in practice, we aim to determine the prevalence and treatment of mental disorders by using routinely collected clinical data contained in EMRs.
We reviewed EMRs of patients randomly sampled from seven general practices, by piloting a study instrument and extracting data on mental disorders and their treatment.
Data were collected on 690 patients (age range 18–95, 52% male, 52% GMS-eligible). A mental disorder (most commonly anxiety/stress, depression and problem alcohol use) was recorded in the clinical records of 139 (20%) during the 2-year study period. While most patients with the common disorders had been prescribed medication (i.e. antidepressants or benzodiazepines), a minority had been referred to other agencies or received psychological interventions. ‘Free text’ consultation notes and ‘prescriptions’ were how most patients with disorders were identified. Diagnostic coding alone would have failed to identify 92% of patients with a disorder.
Although mental disorders are common in general practice, this study suggests their formal diagnosis, disease coding and access to psychological treatments are priorities for future research efforts.