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The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective.
To assess the clinical effectiveness over 6 years and the impact on costs and care home admission.
We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission.
In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35).
START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers.
Declarations of interest
G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.
The date of unique symbolic carvings, from various contexts across north and east Scotland, has been debated for over a century. Excavations at key sites and direct dating of engraved bone artefacts have allowed for a more precise chronology, extending from the third/fourth centuries AD, broadly contemporaneous with other non-vernacular scripts developed beyond the frontiers of the Roman Empire, to the ninth century AD. These symbols were probably an elaborate, non-alphabetic writing system, a Pictish response to broader European changes in power and identity during the transition from the Roman Empire to the early medieval period.
Hydraulic fracturing is a widely used method for well stimulation to enhance hydrocarbon recovery. Permeability, or fluid conductivity, of the hydraulic fracture is a key parameter to determine the fluid production rate, and is principally conditioned by fracture geometry and the distribution of the encased proppant. A numerical model is developed to describe proppant transport within a propagating blade-shaped fracture towards defining the fracture conductivity and reservoir production after fracture closure. Fracture propagation is formulated based on the PKN-formalism coupled with advective transport of an equivalent slurry representing a proppant-laden fluid. Empirical constitutive relations are incorporated to define rheology of the slurry, proppant transport with bulk slurry flow, proppant gravitational settling, and finally the transition from Poiseuille (fracture) flow to Darcy (proppant pack) flow. At the maximum extent of the fluid-driven fracture, as driving pressure is released, a fracture closure model is employed to follow the evolution of fracture conductivity with the decreasing fluid pressure. This model is capable of accommodating the mechanical response of the proppant pack, fracture closure of potentially contacting rough surfaces, proppant embedment into fracture walls, and most importantly flexural displacement of the unsupported spans of the fracture. Results show that reduced fluid viscosity increases the length of the resulting fracture, while rapid leak-off decreases it, with both characteristics minimizing fracture width over converse conditions. Proppant density and size do not significantly influence fracture propagation. Proppant settling ensues throughout fracture advance, and is accelerated by a lower viscosity fluid or greater proppant density or size, resulting in accumulation of a proppant bed at the fracture base. ‘Screen-out’ of proppant at the fracture tip can occur where the fracture aperture is only several times the diameter of the individual proppant particles. After fracture closure, proppant packs comprising larger particles exhibit higher conductivity. More importantly, high-conductivity flow channels are necessarily formed around proppant banks due to the flexural displacement of the fracture walls, which offer preferential flow pathways and significantly influence the distribution of fluid transport. Higher compacting stresses are observed around the edge of proppant banks, resulting in greater depths of proppant embedment into the fracture walls and/or an increased potential for proppant crushing.
Competing risks are a necessary consideration when analyzing risk factors for nosocomial infections (NIs). In this article, we identify additional information that a competing risks analysis provides in a hospital setting. Furthermore, we improve on established methods for nested case-control designs to acquire this information.
Using data from 2 Spanish intensive care units and model simulations, we show how controls selected by time-dynamic sampling for NI can be weighted to perform risk-factor analysis for death or discharge without infection. This extension not only enables hazard rate analysis for the competing risk, it also enables prediction analysis for NI.
The estimates acquired from the extension were in good agreement with the results from the full (real and simulated) cohort dataset. The reduced dataset results averted any false interpretation common in a competing-risks setting.
Using additional information that is routinely collected in a hospital setting, a nested case-control design can be successfully adapted to avoid a competing risks bias. Furthermore, this adapted method can be used to reanalyze past nested case-control studies to enhance their findings.
Bòbila Madurell-Can Gambús is the most emblematic Neolithic cemetery in the northeastern Iberian peninsula, with a total of 179 documented pit burials. Artifacts made of exogenous raw materials, such as honey flint (southeastern France), jadeite, amphibolite, eclogite and nephrite (Alps and the Pyrenees), variscite (coast of northeastern Iberia), and even obsidian (Sardinia), have been found in the burials. The presence of these raw materials is not exclusive to this necropolis, but they have also been documented in many of the graves of this region during this period. The literature has singled out this funerary practice as the Pit Burials cultural horizon. However, until now the chronology of this funerary practice has not been fully defined, so it was difficult to explain the development of the chronology and the networks through which the materials reached northeast Iberia. New, unpublished radiocarbon (14C) dates of Bòbila Madurell-Can Gambús are presented, as well as the results of different statistical analyses and Bayesian modeling that specify its chronology. Through the contribution of new data on the chronology of Bòbila Madurell-Can Gambús new clues regarding the temporal dynamics of pit burials and the raw materials exchange networks associated with them are presented.
The anti-inflammatory mechanisms of low-fat dairy product consumption are largely unknown. The objective of this study was to determine whether low-fat yogurt reduces biomarkers of chronic inflammation and endotoxin exposure in women. Premenopausal women (BMI 18·5–27 and 30–40 kg/m2) were randomised to consume 339 g of low-fat yogurt (yogurt non-obese (YN); yogurt obese (YO)) or 324 g of soya pudding (control non-obese; control obese (CO)) daily for 9 weeks (n 30/group). Fasting blood samples were analysed for IL-6, TNF-α/soluble TNF II (sTNF-RII), high-sensitivity C-reactive protein, 2-arachidonoyl glycerol, anandamide, monocyte gene expression, soluble CD14 (sCD14), lipopolysaccharide (LPS), LPS binding protein (LBP), IgM endotoxin-core antibody (IgM EndoCAb), and zonulin. BMI, waist circumference and blood pressure were also determined. After 9-week yogurt consumption, YO and YN had decreased TNF-α/sTNFR-RII. Yogurt consumption increased plasma IgM EndoCAb regardless of obesity status. sCD14 was not affected by diet, but LBP/sCD14 was lowered by yogurt consumption in both YN and YO. Yogurt intervention increased plasma 2-arachidonoylglycerol in YO but not YN. YO peripheral blood mononuclear cells expression of NF-κB inhibitor α and transforming growth factor β1 increased relative to CO at 9 weeks. Other biomarkers were unchanged by diet. CO and YO gained approximately 0·9 kg in body weight. YO had 3·6 % lower diastolic blood pressure at week 3. Low-fat yogurt for 9 weeks reduced biomarkers of chronic inflammation and endotoxin exposure in premenopausal women compared with a non-dairy control food. This trial was registered as NCT01686204.
Reconciliation of unpaid care and employment is an increasingly important societal, economic and policy issue, both in the UK and internationally. Previous research shows the effectiveness of formal social care services in enabling carers to remain in employment. Using quantitative and qualitative data collected from carers and the person they care for in 2013 and 2015, during a period of cuts to adult social care in England, we explore barriers experienced to receipt of social care services. The main barriers to receipt of services identified in our study were availability, characteristics of services such as quality, and attitudes of carer and care-recipient to receiving services. These barriers have particular implications for carers' ability to reconcile care and employment.
Based on findings from the literature on campaign effects on the one hand, and the literature on European Parliament elections on the other, we propose a model of European Parliamentary elections in which the campaign shift the calculus of electoral support, making differences in national political allegiances less important and attitudes about the European project more important by informing voters of and getting them interested in European politics. In effect, we argue that the political campaign leading up to the election makes European Parliament elections less second order. While previous studies have demonstrated that EU issues can matter for voting behavior in European Parliament elections, existing research has drawn on post-election surveys that do not enable us to capture campaign effects. Our contribution is to assess the impact of a campaign by utilizing a rolling cross-sectional survey that enables us to track how voters were affected by the campaign. Our findings show that campaigns do have an effect on European Parliament election outcomes, in that they provide information that enables voters to make decisions based on their attitude on European issues, making voter decision-making more dominated by EU issue voting.
During 1998–2011, in an area of western Cyprus spanning about one-quarter of the global breeding range of the endemic Cyprus Warbler Sylvia melanothorax, the species declined at a rate of c.59% decade-1, suggesting that there is an urgent need to review its global conservation status. This decline has coincided with the recent, rapid colonisation of western Cyprus by the Sardinian Warbler S. melanocephala, whose numbers have increased substantially within the study area, as might be expected of a newly colonising breeding species. To identify possible causes of the Cyprus Warbler’s decline we compared its rate of change with measures of land-cover, vegetation density, altitude, rainfall and the presence of Sardinian Warblers at survey sites. The rate of decline in the Cyprus Warbler’s abundance was strongly correlated with land-cover and with the duration of site occupancy by Sardinian Warbler; Cyprus Warbler abundance had declined more steeply on sites colonised by Sardinian Warblers early in the survey period than on sites colonised later. Furthermore, on sites surveyed by BirdLife Cyprus in 2006–2014, Cyprus Warbler abundance had continued to decline significantly (also by c.59% decade-1) in western Cyprus, while Sardinian Warbler abundance had continued to increase. In contrast, Cyprus Warbler abundance showed no significant change in central and eastern Cyprus, where Sardinian Warblers were sparse or absent during the breeding season. These findings are consistent with at least two contrasting scenarios: that changes have occurred in land-cover or climatic conditions in Cyprus, to the detriment of Cyprus Warbler and to the benefit of Sardinian Warbler; or that in western Cyprus at least, the two species may compete for similar resources, despite a lack of evidence of this in an earlier, more detailed study. In either case, we suggest the need for a thorough, nationwide breeding survey of the two species.
The long-distance transport of the bluestones from south Wales to Stonehenge is one of the most remarkable achievements of Neolithic societies in north-west Europe. Where precisely these stones were quarried, when they were extracted and how they were transported has long been a subject of speculation, experiment and controversy. The discovery of a megalithic bluestone quarry at Craig Rhos-y-felin in 2011 marked a turning point in this research. Subsequent excavations have provided details of the quarrying process along with direct dating evidence for the extraction of bluestone monoliths at this location, demonstrating both Neolithic and Early Bronze Age activity.
This paper explores the effectiveness of paid services in supporting unpaid carers’ employment in England. There is currently a new emphasis in England on ‘replacement care’, or paid services for the cared-for person, as a means of supporting working carers. The international evidence on the effectiveness of paid services as a means of supporting carers’ employment is inconclusive and does not relate specifically to England. The study reported here explores this issue using the 2009/10 Personal Social Services Survey of Adult Carers in England. The study finds a positive association between carers’ employment and receipt of paid services by the cared-for person, controlling for covariates. It therefore gives support to the hypothesis that services for the cared-for person are effective in supporting carers’ employment. Use of home care and a personal assistant are associated on their own with the employment of both men and women carers, while use of day care and meals-on-wheels are associated specifically with women's employment. Use of short-term breaks are associated with carers’ employment when combined with other services. The paper supports the emphasis in English social policy on paid services as a means of supporting working carers, but questions the use of the term ‘replacement care’ and the emphasis on ‘the market’.
To build on prior correlational research into personal best (PB) goals and motivational outcomes, an experimental study was conducted to assess the role of PB goal setting in gains (or declines) in students’ motivation in science (viz. biology, anatomy, health). The study (comprising N = 71 elementary/primary and secondary school students) applied a pre/post-treatment/control group experimental design to test whether setting a PB learning goal in a self-paced science education program (conducted in a museum context) leads to growth in science valuing and science aspirations. The treatment group (PB goal setting), but not the control group, demonstrated significant growth in science aspirations (but not valuing) between pre- and post-testing. This study provides support for the proposition that PB learning goals are associated with motivational growth in students’ lives. Findings also hold implications for museum-based education programs for students.
We assess the potential of network motif profiles to characterize ego-networks in much the same way that a bag-of-words strategy allows text documents to be compared in a vector space framework. This is potentially valuable as a generic strategy for comparing nodes in a network in terms of the network structure in which they are embedded. In this paper, we consider the computational challenges and model selection decisions involved in network motif profiling. We also present three case studies concerning the analysis of Wikipedia edit networks, YouTube spam campaigns, and peer-to-peer lending in the Prosper marketplace.
Excavations at Tinney's Lane, Sherborne in 2002 uncovered extensive evidence for Late Bronze Age settlement and pottery production, dating from a short time period probably within the 12th or 11th century cal bc. Well-preserved deposits of burnt stone, broken vessels, and burnt sherds, together with resulting debris redeposited in associated pits, were accompanied by a series of post-hole structures interpreted as round-houses and four-post settings. Environmental evidence in the form of charcoal, charred plant remains, and molluscs has provided important information concerning sources of fuel and water for pottery production as well as allowing a reconstruction of the local vegetation. Finds of fired clay, metal, stone, shale, flint, and bone include items from distant sources, informing topics such as site status and exchange, and include many categories of tools and equipment that would have been used within the pottery-making processes. Analysis of the spatial distribution of these finds amongst the structures and surviving layers of burning has allowed the definition of a series of industrial activity areas, each comprising one or more round-houses, a four-post structure, bonfire bases or pits used for firing, and other pits with specific related functions. Altogether the site has provided some of the best evidence for pottery production within prehistoric Britain.
Agricultural production systems that reduce the use of in-crop herbicides
could greatly reduce risks of environmental damage and the development of
herbicide-resistant weeds. Few studies have investigated the long-term
effects of in-crop herbicide omissions on weed seedbank community size and
structure. A crop-rotation study was sampled 10 yr after a strictly annual
rotation and an annual/perennial rotation were exposed to different in-crop
herbicide omission treatments. In-crop herbicides were applied either in all
annual crops (control), omitted from oats only, or omitted from both flax
and oats. Seedbank densities were greatest when in-crop herbicides were
omitted from flax and oats, and this treatment also reduced crop yield.
Shannon-Wiener diversity differed among crops in the annual crop rotation
and among herbicide omission treatments in the perennial rotation. Herbicide
omissions changed the weed-community structure in flax and in wheat and
canola crops in the annual rotation enough to warrant alternate control
methods in some treatments. The magnitude of the effects on the seedbank
parameters depended largely on the competitive ability of the crop in which
herbicides were omitted. No yield response to omitting herbicides in oats
indicated that standard weed management practices have reduced weed
populations below yield-loss thresholds.
High electron mobility transistors (HEMTs) based on the InAlAs/InGaAs heterostructure have been grown on InP by molecular beam epitaxy. At room temperature, typical sheet charge densities of 2.1–3.0×1012 cm−2 and Hall electron mobilities over 10000 cm2 /V-s are obtained. An electron mobility as high as 13000 cm2 /V-s is achieved with a pseudomorphic Iny Ga1−y As channel and a y value of 0.70.
HEMTs with a T- or Γ-shaped gate and with gate lengths ranging from 0.1–0.25 urn have been fabricated. A record low noise figure of 0.7 dB with an associated gain of 8.6 dB at 62 GHz has been achieved with 0.1 μm Γ-gate devices, while T-gate devices exhibit a minimum noise figure of 1.2 dB with 7.2 dB associated gain at 94 GHz. Separately, a record fmax value of 455 GHz was determined by extrapolating at -6 dB/octave from the measured gain of 13.6 dB at 95 GHz.
Power HEMTs using a double heterojunction structure exhibit a record peak power-added efficiency (P.A.E.) of 49% with 8.6 dB power gain and 0.30 W/mm power density measured at 60 GHz. When biased and tuned for maximum output power, our best 60 GHz output power density to date is 0.52 W/mm with 33% P.A.E. and 5.9 dB power gain using a single heterojunction HEMT scheme with pseudomorphic channel. A similar device also yields peak P.A.E. of 26% with 0.20 W/mm power density and 4.9 dB gain at 94 GHz. These results represent the highest P.A.E.S and power gains ever reported for any transistor at these frequencies.
A nitrogen-free (N-free) dielectric anti-reflective coating (DARC®) was cost-effectively developed in a plasma-enhanced chemical vapor deposition (PECVD) reactor to eliminate the 193nm resist poisoning interaction caused when N2O is used as a precursor . Although it was found that even a N-free ARC could poison sensitive 193nm resists with –OH radicals , which either exist inherently in the ARC or result from H2O absorption by the ARC surface, the current investigation has revealed that it was possible to minimize resist poisoning. Our investigation showed that compressive film stress directly correlates to H2O resistance. Therefore, it was possible to greatly improve the ARC resistance to H2O absorption by creating and maintaining a process regime that makes the ARC film dense. The dense ARC film demonstrated promising lithography performance with minimal resist poisoning as well as excellent shelf life and O2-ashing resistance. This paper explores the N-free DARC material, its development, lithographic integration results and implementation in a production environment to eliminate 193nm resist poisoning.