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Feeding fodder beet (FB) to dairy cows in early lactation has recently been adopted by New Zealand dairy producers despite limited definition of feeding and grazing management practices that may prevent acute and sub-acute ruminal acidosis (SARA). This modelling study aimed to characterize changes of rumen pH, milk production and total discomfort from FB and define practical feeding strategies of a mixed herbage and FB diet. The deterministic, dynamic and mechanistic model MINDY was used to compare a factorial arrangement of FB allowance (FBA), herbage allowance (HA) and time of allocation. The FBA were 0, 2, 4 or 7 kg dry matter (DM)/cow/day (0FB, 2FB, 4FB and 7FB, respectively) and HA were 18, 24 or 48 kg DM/cow/day above ground. All combinations were offered either in the morning or afternoon or split across two equal meals. Milk production from 2FB diets was similar to 0FB but declined by 4 and 16% when FB increased to 4 and 7 kg DM, respectively. MINDY predicted that 7FB would result in SARA and that rumen conditions were sub-optimal even at moderate FBA (pH < 5.6 for 160 and 90 min/day, 7FB and 4FB respectively). Pareto front analysis identified the best compromise between high milk production and low total discomfort was achieved by splitting the 2FB diet into two equal meals fed each day with 48 kg DM herbage. However, due to low milk response and high risk of acidosis, it is concluded that FB is a poor supplement for lactating dairy cows.
Having been tasked with developing Standards for integrated care pathways for mental health (ICP), successfully publishing in 2007, NHS Quality Improvement Scotland (NHS QIS) now supports NHS Boards in developing and implementing these standards. Support is available via three National ICP Coordinators and local ICP facilitators.
The main objective is for Boards to achieve ICP accreditation, resulting in demonstration of a robust and responsive mental health system through implementation of their local ICPs supporting continuous cycles of quality improvement embedded in a culture that ensures delivery of person-centred care and reflective practice.
A model of and process for accreditation was developed considering: § Developing the project plan§ Reaching consensus on the goal of the accreditation initiative.§ Defining incentives for stakeholders in having ICPs accredited § Reviewing literature on existing accreditation systems in UK and internationally § Developing a range of options§ Carrying out an option appraisal§ Agreeing one preferred option § Obtaining NHS QIS and Scottish Government approval for preferred option§ Further development of support mechanisms and implementation of a longer term accreditation framework
A phased and incremental accreditation system was developed.
The first phase - “foundation level” - focuses on ensuring that appropriate infrastructures are in place to support full ICP development and implementation in NHS Board.
All 14 NHS Boards in Scotland achieved foundation level accreditation.
Reflection on this first phase are helping to inform NHS QIS on how best to structure future levels of accreditation and ongoing support over the next few years.
Patients with SMI receive long term intervention with psychotropic agents often associated with weight gain. Weight and lifestyle management programmes may prevent, reduce or reverse weight gain, however most data is short-term. Categorical data is not often reported
A group programme (Solutions for Wellness) designed to address weight and other cardiovascular risk factors commenced 2002 in Ireland. Each group provided open-ended access to referred SMI patients. Weekly group sessions consisted weighing, discussion and an 8-week rotational cycle of educational topics on aspects of weight, dietary choices and lifestyle changes. Groups were led by trained healthcare professionals.
Data is reported up to 24 months from 55 patients (27 male; 28 female) from 6 centres. Mean age 49.4 years (range 21-74). Schizophrenia 63%, Affective disorders 26%, other 11%. Patients completing 1 year - 55% and 2 years 22%. Baseline mean weight 98.6 kg (SD 19.2) decreased to final visit weight 96.9kg (SD 18.4).Paired t –test, p = 0.0030; CI Mean 2.53 (0.9-4.159). Weight increased in 11/55, maintained 7/55 and decreased 37/55.
Weight gain in SMI patients is not inevitable and was found in only 20% of patients attending weight clinics in Ireland. Patients may benefit if similar interventions were widely available.
The air gap technique (AGT) is an approach to radiation dose optimisation during fluoroscopy where an “air gap” is used in place of an anti-scatter grid to reduce scatter irradiation. The AGT is effective in adults but remains largely untested in children. Effects are expected to vary depending on patient size and the amount of scatter irradiation produced.
Fluoroscopy and cineangiography were performed using a Phillips Allura Fluoroscope on tissue simulation anthropomorphic phantoms representing a neonate, 5-year-old, and teenager. Monte Carlo simulations were then used to estimate effective radiation dose first using a standard recommended imaging approach and then repeated using the AGT. Objective image quality assessments were performed using an image quality phantom.
Effective radiation doses for the neonate and 5-year-old phantom increased consistently (2–92%) when the AGT was used compared to the standard recommended imaging approaches in which the anti-scatter grid is removed at baseline. In the teenage phantom, the AGT reduced effective doses by 5–59%, with greater dose reductions for imaging across the greater thoracic dimension of lateral projection. The AGT increased geometric magnification but with no detectable change in image blur or contrast differentiation.
The AGT is an effective approach for dose reduction in larger patients, particularly for lateral imaging. Compared to the current dose optimisation guidelines, the technique may be harmful in smaller children where scatter irradiation is minimal.
We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.
One of the most important and valuable resources available to researchers of eighteenth-century social history are the lists of subscribers that were attached to a wide variety of publications. Yet, the study of this type of resource remains one of the areas most neglected by academics. These lists shed considerable light on the nature of those who subscribed to music, including their social status, place of employment, residence, and musical interests. They naturally also provide details as to the gender of individual subscribers.
As expected, subscribers to most musical publications were male, but the situation changed considerably as the century progressed, with more females subscribing to the latest works by the early nineteenth century. There was also a marked difference in the proportion of male and female subscribers between works issued in the capital cities of London and Edinburgh and those written for different genres. Female subscribers also appear on lists to works that they would not ordinarily be permitted to play. Ultimately, a broad analysis of a large number of subscription lists not only provides a greater insight into the social and economic changes that took place in Britain over the course of the eighteenth century, but also reveals the types of music that were favoured by the members of each gender.
The aim of this study was to describe previously unrecognised or under-recognised adverse events associated with Melody® valve implantation.
In rare diseases and conditions, it is typically not feasible to conduct large-scale safety trials before drug or device approval. Therefore, post-market surveillance mechanisms are necessary to detect rare but potentially serious adverse events.
We reviewed the United States Food and Drug Administration’s Manufacturer and User Facility Device Experience (MAUDE) database and conducted a structured literature review to evaluate adverse events associated with on- and off-label Melody® valve implantation. Adverse events were compared with those described in the prospective Investigational Device Exemption and Post-Market Approval Melody® transcatheter pulmonary valve trials.
We identified 631 adverse events associated with “on-label” Melody® valve implants and 84 adverse events associated with “off-label” implants. The most frequent “on-label” adverse events were similar to those described in the prospective trials including stent fracture (n=210) and endocarditis (n=104). Previously unrecognised or under-recognised adverse events included stent fragment embolisation (n=5), device erosion (n=4), immediate post-implant severe valvar insufficiency (n=2), and late coronary compression (n=2 cases at 5 days and 3 months after implantation). Under-recognised adverse events associated with off-label implantation included early valve failure due to insufficiency when implanted in the tricuspid position (n=7) and embolisation with percutaneous implantation in the mitral position (n=5).
Post-market passive surveillance does not demonstrate a high frequency of previously unrecognised serious adverse events with “on-label” Melody® valve implantation. Further study is needed to evaluate safety of “off-label” uses.
Previous studies have identified risk factors for femoral arterial thrombosis after paediatric cardiac catheterisation, but none of them have evaluated the clinical and economic significance of this complication at the population level. Therefore, we examined the national prevalence and economic impact of femoral arterial thrombosis after cardiac catheterisation in children.
Patients⩽18 years of age who underwent cardiac catheterisation were identified in the 2003–2009 Kids’ Inpatient Database. Patients were stratified by age as follows: <1 year of age or 1–18 years of age. The primary outcome was arterial thrombosis of the lower extremity during the same hospitalisation as cardiac catheterisation. Propensity score matching was used to determine the impact of femoral arterial thrombosis on hospital length of stay, cost, and mortality.
Among the 11,497 paediatric cardiac catheterisations identified, 4558 catheterisations (39.6%) were performed in children <1 year of age. This age group experienced a higher prevalence of reported femoral arterial thrombosis, compared with children aged 1–18 years (1.3 versus 0.3%, p<0.001). After matching, femoral arterial thrombosis in children <1 year of age was associated with similar mortality (5.4 versus 1.8%, p=0.28), length of stay (8 versus 5 days, p=0.11), and total hospital cost ($27,135 versus $28,311, p=0.61), compared with absence of thrombosis.
Femoral arterial thrombosis is especially prevalent in children <1 year of age undergoing cardiac catheterisation. Clinicians should be vigilant in monitoring femoral arterial patency in neonates and infants after cardiac catheterisation.
The Hanson Formation, Antarctica, consists of interbedded sandstones and tuffaceous rocks of Early Jurassic age. The sandstones, pebbly to medium-grained, range between quartzo-feldspathic and volcaniclastic, with some of the former being coarse-grained arkoses that imply proximal sources. Geochronology of detrital zircons provides evidence for source rock ages, whereas sandstone petrology demonstrates a mixed provenance. Tuffaceous strata are reworked fine to very fine-grained tuffs resulting from distal Plinian eruptions. Dated tuffs provide time constraints on the duration of volcanism. The sandstones and tuffs accumulated in a rift environment. Geochemically the tuffs are rhyolitic in composition, and the Sr and Nd isotope data together with the patterns on multi-element diagrams suggest they were derived from a volcanic arc, which is interpreted to have been located along the West Antarctic Gondwana margin. The silicic volcanism extends the distribution and timing of magmatism in the Early Jurassic along that margin. The Early Jurassic extensional regime was delimited by the plate margin region and the East Antarctic craton. The rift valley system along the East Antarctic craton margin, in which the Hanson strata accumulated, was the focus for subsequent emplacement of the intrusive and extrusive rocks of the Lower Jurassic Ferrar Large Igneous Province. The Early Jurassic extensional rifts may have been reactivated during Cretaceous–Cenozoic development of the West Antarctic Rift System.
We studied the spread of influenza in the community between 1993 and 2009 using primary-care surveillance data to investigate if the onset of influenza was age-related. Virus detections [A(H3N2), B, A(H1N1)] and clinical incidence of influenza-like illness (ILI) in 12·3 million person-years in the long-running Royal College of General Practitioners-linked clinical-virological surveillance programme in England & Wales were examined. The number of days between symptom onset and the all-age peak ILI incidence were compared by age group for each influenza type/subtype. We found that virus detection and ILI incidence increase, peak and decrease were in unison. The mean interval between symptom onset to peak ILI incidence in virus detections (all ages) was: A(H3N2) 20·5 [95% confidence interval (CI) 19·7–21·6] days; B, 18·8 (95% CI 15·8·0–21·7) days; and A(H1N1) 17·0 (95% CI 15·6–18·4) days. Differences by age group were examined using the Kruskal–Wallis test. For A(H3N2) and A(H1N1) viruses the interval was similar in each age group. For influenza B there were highly significant differences by age group (P = 0·0001). Clinical incidence rates of ILI reported in the 8 weeks preceding the period of influenza virus activity were used to estimate a baseline incidence and threshold value (upper 95% CI of estimate) which was used as a marker of epidemic progress. Differences between the age groups in the week in which the threshold was reached were small and not localized to any age group. In conclusion we found no evidence to suggest that influenza A(H3N2) and A(H1N1) occurs in the community in one age group before another. For influenza B, virus detection was earlier in children aged 5–14 years than in persons aged ⩾25 years.
Influenza is rarely laboratory-confirmed and the outpatient influenza burden is rarely studied due to a lack of suitable data. We used the Clinical Practice Research Datalink (CPRD) and surveillance data from Public Health England in a linear regression model to assess the number of persons consulting UK general practitioners (GP episodes) for respiratory illness, otitis media and antibiotic prescriptions attributable to influenza during 14 seasons, 1995–2009. In CPRD we ascertained influenza vaccination status in each season and risk status (conditions associated with severe influenza outcomes). Seasonal mean estimates of influenza-attributable GP episodes in the UK were 857 996 for respiratory disease including 68 777 for otitis media, with wide inter-seasonal variability. In an average season, 2·4%/0·5% of children aged <5 years and 1·3%/0·1% of seniors aged ⩾75 years had a GP episode for respiratory illness attributed to influenza A/B. Two-thirds of influenza-attributable GP episodes were estimated to result in prescription of antibiotics. These estimates are substantially greater than those derived from clinically reported influenza-like illness in surveillance programmes. Because health service costs of influenza are largely borne in general practice, these are important findings for cost-benefit assessment of influenza vaccination programmes.
To investigate the extent to which enteric methane (CH4) emissions from growing lambs are explained by simple body weight and diet characteristics, a 2 × 2 Latin square changeover design experiment was carried out using two sheep breeds and two fresh pasture types. Weaned lambs of two contrasting breed types were used: Welsh Mountain (WM, a small, hardy hill breed) and Welsh Mule × Texel (TexX, prime lamb) (n = 8 per breed). The lambs were zero-grazed on material cut from recently reseeded perennial ryegrass and extensively managed permanent pasture. In each experimental period, individual ad libitum dry matter intake (DMI) was determined indoors following an adaptation period of 2 weeks, and CH4 emissions were measured individually in open-circuit respiration chambers over a period of 3 days. Although total daily CH4 emissions were lower for the WM lambs than for the TexX lambs (13·3 v. 15·7 g/day, respectively) when offered fresh forage, the yield of CH4 per unit DMI was similar for the two breed types (16·4 v. 17·7 g CH4/kg DMI). Total output of CH4 per day was higher when lambs were offered ryegrass compared with permanent pasture (16·1 v. 12·9 g/day, respectively), which was probably driven by differences in DMI (986 v. 732 g/day). Methane emissions per unit DMI (16·4 v. 17·7 g CH4/kg DMI) and proportion of gross energy intake excreted as CH4 (0·052 v. 0·056 MJ/MJ) were both higher on the permanent pasture. No forage × breed type interactions were identified. The results indicate that forage type had a greater impact than breed type on CH4 emissions from growing weaned lambs. It can be concluded that when calculating CH4 emissions for inventory purposes, it is more important to know what forages growing lambs are consuming than to know what breeds they are.
To identify factors associated with the development of surgical site infection (SSI) among adult patients undergoing renal transplantation
A retrospective cohort study
An urban tertiary care center in Baltimore, Maryland, with a well-established renal transplantation program that performs ~200–250renal transplant procedures annually
At total of 441 adult patients underwent renal transplantation between January 1, 2010, and December 31, 2011. Of these 441patients, 66 (15%) developed an SSI; of these 66, 31 (47%) were superficial incisional infections and 35 (53%) were deep-incisional or organ-space infections. The average body mass index (BMI) among this patient cohort was 29.7; 84 (42%) were obese (BMI >30). Patients who developed an SSI had a greater mean BMI (31.7 vs 29.4; P=.004) and were more likely to have a history of peripheral vascular disease, rheumatologic disease, and narcotic abuse. History of cerebral vascular disease was protective. Multivariate analysis showed BMI (odds ratio [OR] 1.06; 95% confidence interval [CI], 1.02–1.11) and past history of narcotic use/abuse (OR, 4.86; 95% CI, 1.24–19.12) to be significantly associated with development of SSI after controlling for National Healthcare Surveillance Network (NHSN) score and presence of cerebrovascular, peripheral vascular, and rheumatologic disease.
We identified higher BMI as a risk factor for the development of SSI following renal transplantation. Notably, neither aggregate comorbidity scores nor NHSN risk index were associated with SSI in this population. Additional risk adjustment measures and research in this area are needed to compare SSIs across transplant centers.
Key features of quantum mechanics are the uncertainty principle, wave–particle duality, quantization of energies and the modification of classical probability laws. Biology is concerned with how natural systems function – from understanding how genetically coded information is replicated, to attaining a mechanistic model for complex multistep reactions. Recently researchers have been asking whether quantum mechanics, normally the domain of physics, is also needed to understand some biological processes. This field includes fascinating developments in theory and experiment, as well as multidisciplinary discussion, and the state-of-the-art is documented in this book. Erwin Schrödinger, in his famous book What is Life? (Schrödinger, 1944), noted that quantum mechanics accounts for the stability of living things and their cellular processes because of our understanding, via quantum mechanics, of the stability and structure of molecules. The fact that quantum effects create, sometimes large, energy gaps between different states of a chemical system is also important. Such energy gaps, between electronic energy levels, enable living organisms to capture and store the energy carried from the sun by photons, and to visualize the world around them via optically induced chemical reactions. Davydov's view in Biology and Quantum Mechanics (Davydov, 1982) was that quantum mechanics is most relevant for isolated systems in pure states and therefore is of little importance for biological systems that are in statistical states at thermal equilibrium.
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.
The objective of the current study was to compare the outcomes of rigid endoscopic procedures with those of pre-operative flexible nasoendoscopy.
A total of 253 patients who had undergone rigid endoscopic examination under anaesthesia between 6 January 2010 and 31 August 2011 were identified. Their clinical, surgical and histological records were evaluated.
A total of 213 patients had a flexible nasoendoscopic procedure performed and recorded pre-operatively, and 82 in this cohort had a specific lesion or area of concern identified. There were 21 confirmed malignant biopsy results, the majority of which were squamous cell carcinoma. No patient with a negative pre-operative endoscopy had a malignant lesion discovered on endoscopic biopsy. The sensitivity and specificity of pre-operative nasoendoscopy were 100 per cent and 66.3 per cent, respectively.
Diagnostic rigid endoscopic examination of the upper aerodigestive tract remains an important tool for excluding malignancy in high-risk patients, but is an unnecessary procedure in those low-risk patients with normal pre-operative findings.