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Introduction: Individualizing risk for stroke following a transient ischemic attack (TIA) is a topic of intense research, as existing scores are context-dependent or have not been well validated. The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk. Our objective was to prospectively validate the Canadian TIA Score in a new cohort of emergency department (ED) patients. Methods: We conducted a prospective cohort study in 14 Canadian EDs over 4 years. We enrolled consecutive adult patients with an ED visit for TIA or nondisabling stroke. Treating physicians recorded standardized clinical variables onto data collection forms. Given the ability of prompt emergency carotid endarterectomy (CEA) to prevent stroke (NNT = 3) in high risk patients, our primary outcome was the composite of subsequent stroke or CEA ≤7 days. We conducted telephone follow-up using the validated Questionnaire for Verifying Stroke Free Status at 7 and 90 days. Outcomes were adjudicated by panels of 3 local stroke experts, blinded to the index ED data collection form. Based on prior work, we estimated a sample size of 5,004 patients including 93 subsequent strokes, would yield 95% confidence bands of +/− 10% for sensitivity and likelihood ratio (LR). Our analyses assessed interval LRs (iLR) with 95% CIs. Results: We prospectively enrolled 7,569 patients with mean 68.4 +/−14.7 years and 52.4% female, of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days (total outcomes = 181). We enrolled 81.2% of eligible patients; missed patients were similar to enrolled. The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low (probability <0.2%, iLR 0.20 [95%CI 0.091-0.44]; Moderate (probability 1.3%, iLR 0.79 [0.68-0.92]; High (probability 2.6%, iLR 2.2 [1.9-2.6]. Sensitivity analysis for just stroke ≤7 days yielded similar results: Low iLR 0.17 [95%CI 0.056-0.52], Medium iLR 0.89 [0.75-1.1], High iLR 2.0 [1.6-2.4]. Conclusion: The Canadian TIA Score accurately identifies TIA patients risk for stroke/CEA ≤7 days. Patients classified as low risk can be safely discharged following a careful ED assessment with elective follow-up. Patients at moderate risk can undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up. Patients at high risk should in most cases be fully investigated and managed ideally in consultation with a stroke specialist during their index ED visit.
Introduction: Carotid artery stenosis (CAS) is a common cause of stroke. Patients with severe, symptomatic CAS can have their subsequent stroke risk reduced by carotid endarterectomy or stenting when completed soon after a TIA or non-disabling stroke. Patients presenting to a peripheral ED with TIA/stroke, may require transfer to another hospital for imaging to rule-out CAS. The purpose of this study was to determine the test characteristics of carotid artery POCUS in detecting greater than 50% stenosis in patients presenting with TIA/stroke. Methods: We conducted a prospective cohort study on a convenience sample of adult patients presenting to a tertiary care academic ED with TIA/stroke between June and October 2017. Carotid POCUS was performed by a trained medical student or a trained emergency physician. Our outcome measure, CAS >50% was determined by the final radiology report of CTA imaging by a trained radiologist, blinded to our study. A blinded POCUS expert reviewed the carotid POCUS scans. We calculated the sensitivity and specificity for CAS >50% using carotid POCUS versus the gold standard of CTA. Results: We enrolled 75 patients of which 5 did not meet inclusion criteria. The mean age was 70.4 years, 57% were male. 16% were diagnosed with greater than 50% CAS. 47% were stroke codes and 37% were admitted to hospital. Carotid POCUS had a sensitivity and specificity of 72% (46%-99%) and 88% (80%-96%) respectively. There were three false negatives of which two were exactly 50% ICA stenosis on CTA and the other was 100% occlusion of the distal ICA. Kappa coefficient for inter-rater reliability between standard and expert interpretation was 0.68 for moderate agreement. The scan took a mean time of 6.2 minutes to complete. Conclusion: Carotid POCUS has moderate correlation with CTA for detection of CAS greater than 50%. Carotid POCUS identified all the critical 70-99% stenosis lesions that would need urgent surgery. Further research is needed to confirm these findings.
Selective breeding has been an important component in the increased output and efficiency of animal production since the 1950's. At the same time there has been increasing moral concern over the welfare of modern farmed animals with much of the focus on the environment and management of farm animals and relatively little consideration of the impact of genetic change on welfare. This is now changing, partly because of some well-publicised examples where selection has led to ‘undesirable’ side effects, and because of the perceived welfare risk of emerging biotechnologies. This paper will address whether and how moral concerns over animal welfare should place limitations on genetic change in animal production.
Genetic improvement is permanent and cumulative. Improvements made in one generation are passed onto the next. In the UK two selection indexes are currently available to the dairy industry, they are PIN (Profit Index; production only) and £PLI (Profitable Lifetime Index; production plus lifespan). Much of the current and anticipated index research and development will be on broader breeding goals that include health and fertility traits. Economic responses expected for PIN and £PLI over a 20 year period were calculated in addition to a hypothetical index where it was assumed that PTAs (predicted transmitting abilities) for mastitis (M) and calving interval (CI) were available (£PLI+M+CI).
Veerkamp et al. (1998) make the case for including somatic cell count (SCC) in the index of total economic merit (ITEM, Veerkamp et al., 1995) used to rank dairy bulls and cows in the UK for breeding purposes. They go on to describe an empirical method to obtain a suitable economic value for SCC, reflecting the milk quality payment scheme. Since this work was carried out, the milk price has fallen while price penalties against SCC have risen. Bulk-tank SCC (BTSCC) has fallen in response. Some of this improvement may be due to culling cows with high cell counts. The objective of this work was therefore to establish an economic value for somatic cell counts which reflected the milk quality payment scheme and took into account culling strategy.
Background: It has been hypothesized that [18F]-sodium fluoride (NaF) uptake imaged with positron emission tomography (PET) binds to hydroxyapatite molecules expressed in regions with active calcification. Therefore, we aimed to validate NaF as a marker of hydroxyapatite expression in high-risk carotid plaque. Methods: Eleven patients (69 ± 5 years, 3 female) scheduled for carotid endarterectomy were prospectively recruited for NaF PET/CT. One patient received a second contralateral endarterectomy; two patients were excluded (intolerance to contrast media and PET/CT misalignment). The bifurcation of the common carotid was used as the reference point; NaF uptake (tissue to blood ratio - TBR) was measured at every PET slice extending 2 cm above and below the bifurcation. Excised plaque was immunostained with Goldner’s Trichrome and whole-slide digitized images were used to quantify hydroxyapatite expression. Pathology was co-registered with PET. Results: NaF uptake was related to the extent of hydroxyapatite expression (r=0.45, p<0.001). Upon classifying bilateral plaque for symptomatology, symptomatic plaque was associated with cerebrovascular events (3.75±1.1 TBR, n=9) and had greater NaF uptake than clinically silent asymptomatic plaque (2.79±0.6 TBR, n=11) (p=0.04). Conclusion: NaF uptake is related to hydroxyapatite expression and is increased in plaque associated with cerebrovascular events. NaF may serve as a novel biomarker of active calcification and plaque vulnerability.
A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA.
We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography.
Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p=0.037).
Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source.
The incursion of Bluetongue disease into the UK and elsewhere in Northern Europe in 2008 raised concerns about maintaining an appropriate level of preparedness for the encroachment of exotic diseases as circumstances and risks change. Consequently the Scottish government commissioned the present study to inform policy on the specific threat of Bluetongue virus 8 (BTV8) incursion into Scotland. An interdisciplinary expert panel, including BTV and midge experts, agreed a range of feasible BTV incursion scenarios, patterns of disease spread and specific control strategies. The study was primarily desk-based, applying quantitative methodologies with existing models, where possible, and utilizing data already held by different members of the project team. The most likely distribution of the disease was explored given Scotland's agricultural systems, unique landscape and climate. Epidemiological and economic models are integrated in an ex-ante cost-benefit appraisal of successful prevention of hypothetical BTV8 incursion into Scotland under various feasible incursion scenarios identified by the interdisciplinary panel. The costs of current public and private surveillance efforts are compared to the benefits of the avoided losses of potential disease outbreaks. These avoided losses included the direct costs of alternative vaccination, protection zone (PZ) strategies and their influence on other costs arising from an outbreak as predicted by the epidemiological model. Benefit-cost ratios were ranked within each incursion scenario to evaluate alternative strategies. In all incursion scenarios, the ranking indicated that a strategy, including 100% vaccination within a PZ set at Scottish counties along the England–Scotland border yielded the least benefit in terms of the extent of avoided outbreak losses (per unit cost). The economically optimal vaccination strategy was the scenario that employed 50% vaccination and all Scotland as a PZ. The results provide an indicator of how resources can best be targeted for an efficient ex-ante control strategy.
We present the KMOS (K-band Multi-Object Spectrograph) Cluster and VIRIAL (VLT IRIFU Absorption Line) Guaranteed Time Observation (GTO) programs. KMOS provides 24 arms each feeding an integral field unit (14×14 spaxels of 0.2″ pixels) for IZ, YJ, H and K band near infrared (NIR) medium resolution spectroscopy (R ∼ 3500). Targets are selected from a 7.2′ diameter patrol field. Ultra-deep spectroscopy of ∼ 80 early-type cluster galaxies (∼ 20hr on source) and ∼ 200 (∼ 10hr on source) early-type field galaxies at 1 < z < 2 will dramatically improve the situation at z > 1 for which measurements of stellar velocity dispersions and absorption indices are limited to a few, often relatively young passively evolving galaxies (e.g. Bezanson 2013). In ESO Periods P92 and P93, 15 nights worth of data has been collected for KMOS-Clusters and 6 nights for VIRIAL: this will be supplemented with more data in upcoming semesters. All galaxies have multiband HST imaging including existing or upcoming WFC3 IR imaging, providing stellar mass maps and sizes. Combined with our dispersion measurements, this will allow us to examine the fundamental plane and the dynamical mass of a large sample of z > 1 galaxies for the first time, for both cluster and field galaxies.
Some main uses of the versatile genus Salix are described. The basket willow industry, once nationwide but now concentrated in Somerset, is covered in some detail, noting the site requirements and attributes of the three main basket willow species, Salix triandra L., S. viminalis L. and S. purpurea L. The management of the crops and methods of processing to give the ‘white’ or ‘buff’ coloured rods preferred by basket makers are described, as are the ability and versatility of basketry to produce containers uniquely suited to meet specific needs.
Other uses of the shrub willows (sub-genus Vetrix) are outlined, including the stabilisation of slopes and other aspects of bioengineering, amelioration of difficult environments and large-scale amenity urban and motorway plantings.
Attention is drawn to opportunities to develop the tree willows (sub-genus Salix) to meet projected timber shortages, to the use of willows for windbreaks and shelter, and to the culture and use of that very British tree – the Cricket Bat Willow (S. alba var. caerulea (Sm.) Sm.).
An inactivated vaccine against respiratory syncytial virus (RSV) was compared with two live vaccines. The inactivated (GC) vaccine consisted of glutaraldehyde-fixed bovine nasal mucosa cells persistently infected with RSV and emulsified with oil adjuvant. The live vaccines were a modified virus (MV) derived from a bovine strain of RSV and a temperature-sensitive mutant (ts-1) derived from a human strain. The GC vaccine was inoculated subcutaneously into 12 calves and the live vaccines intramuscularly into eight calves each. Nine unvaccinated calves acted as controls. The vaccines were administered in two doses 3 weeks apart and all calves were challenged intranasally with 2 × 107 p.f.u. of bovine RSV 3 weeks after the second dose.
At the time of challenge calves given GC, MV and ts-1 vaccines had mean serum neutralizing antibody titres of 25, 19 and 2 respectively; mean titres of IgG1 antibody by radioimmunoassay were log10 4·5, 1·3 and 2·6 respectively and mean zone areas by single radial haemolysis (SRH) were 107, 27 and 36 mm2 respectively.
Eleven of 12 calves given GC vaccine were completely protected against challenge but all control animals and those given the two live vaccines were infected. The mean peak titre of virus in nasal swabs of control calves was 3.0 log10 p.f.u./ml and the mean duration of virus shedding was 6·8 days. Both these parameters were significantly reduced in animals given MV and ts-1 vaccines: mean peak titres were 2·1 and 2·4 log10 p.f.u./ml and mean duration of shedding was 3·4 and 3·3 days respectively.
Thus, protection correlated better with RSV antibody detected by radio-immunoassay and SRH than with neutralizing antibody. These results are discussed in relation to the possible mechanism by which protection was mediated.
A total of 1590 calves were investigated between May 1972 and December 1975. Twenty-two per cent were treated for respiratory disease and 2·5% died of pneumonia. Almost 80% of the respiratory illness occurred in six sharp outbreaks. Samples for virology were collected routinely from 127 healthy calves and from 354 calves treated for respiratory signs and comprised 1143 nasopharyngeal swabs and 1069 sera. Virus infections were detected on 540 occasions including 135 by parainfluenzavirus type 3 (Pi-3), 78 by respiratory syncytial virus (RSV), 103 by rhinovirus, 49 by bovine virus diarrhoea virus (BVDV), 29 by adenoviruses, 53 by reoviruses and 88 by enteroviruses. The seasonal and age distribution of infections differed between viruses. Only infections by RSV, Pi-3 and BVDV were significantly associated with disease.
In beef suckler herds, reproductive failure is a major cause of financial loss during a bovine viral diarrhoea (BVD) outbreak due to reduction in the numbers of calves, increased calving spread and the financial implications of dealing with infertile cows. These losses may be hidden and/or not fully attributed to BVD. A model of herd dynamics was built and combined with an epidemiological model to encapsulate the disruptions to reproduction that BVD may cause in beef suckler herds and to estimate the associated financial consequences of such disruptions.
Results from the model suggest that the average losses associated with BVD in Scottish beef suckler herds via impaired reproduction alone may vary between £43 and £22/cow/year during the course of a BVD epidemic. These results indicate that an outbreak can be costly and these losses may be hidden by the use of low risk management practices such as a long breeding season, not only in herds with no evidence of antibodies but also in herds where there are some antibody positive (immune) animals.
A new genus and species of eurypterid (Eurypterida: Chelicerata) is described as Orcanopterus manitoulinensis from the Upper Ordovician Kagawong Submember (Upper Member) of the Georgian Bay Formation, Manitoulin Island, Ontario, Canada. The material comprises several partial specimens in addition to disarticulated carapaces, appendages, metastomas, opisthosomal segments, and telsons. Associated fossils include rare bryozoans, a conularid, ostracodes, and conodonts. A restricted marine lagoon, or very shallow subtidal to intertidal environment is inferred. This assemblage, perhaps representing an accumulation of molted exuviae, was apparently preserved as the result of rapid burial by carbonate muds and silts during a storm event. O. manitoulinensis shares a number of traits with both the Hughmilleriidae and the Carcinosomatidae. Diagnostic features include curved preabdominal segments, a petaloid A metastoma with deep anterior emargination, spiniferous appendages of Carcinosoma type, paddle with enlarged, symmetrical podomere 9, and a xiphous telson. It is only the fourth (the first Canadian) well-documented Ordovician eurypterid genus, and provides the oldest reliable record of the Hughmillerioidea to date.
Cerebral multi-infarct states (MIS) have a very variable clinical presentation (Table 1). Dementia is often stressed as the primary feature, however, many patients have relative preservation of cognitive abilities and personality, although their mobility may be severely affected, with a small-stepped shuffling gait, poor balance and frequent falls associated with bilateral (often asymmetrical) pyramidal tract signs. Urinary incontinence is common, dysphagia and dysarthria may occur, and some patients develop emotionalism and/or depression. In the later stages, patients may become immobile, requiring 24-hour nursing care.
Predicted transmitting abilities for somatic cell counts (SCC) are available in the United Kingdom and there is a direct economic benefit attached to reducing SCC as the milk payment schemes include a penalty for high SCC levels in bulk tank samples and sometimes a premium for low SCC. The aim of the present study was to establish the economic importance of bulls' breeding values for SCC in relation to this payment scheme for SCC. To do this, an empirical method was developed using 645071 individual cow SCC and milk yield test-day records from 358 herds. The economic value was calculated by (i) decreasing all individual cow records by 0·01 and comparing the average penalty with the current average penalty, and (ii) taking the derivative of a Gompertz function describing the within-herd penalty per cow as a function of the average within-herd 3-month rolling geometric mean SCC. Mean milk test-day yield and average test-day SCC were 20·4 kg and 262 kcount per ml respectively with, on average, 83 cows tested each day. In the current situation the average penalty paid was 0·54, 0·18 and 3·2 pence per litre depending on whether an England and Wales, Scottish or future payment scheme was used, respectively. Across the population, the economic values per 0·01 decrease in SCC were £1·04, £0·54 and £6·03 per cow per year for these three payments schemes respectively. However these economic values depend strongly on the mean SCC. Herds have different means and as the future population mean is difficult to predict, it is suggested that for herds with the majority of their bulk tank samples in penalty bands 1, 2 or 3+ (average SCC of <150, 150 to 250 and 250+) the economic values are £0, £0·50, and £15 per cow per year per 0·01 reduction in SCC, respectively, until additional benefits have been quantified.