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The peoples of southern Mesoamerica, including the Classic period Maya, are often claimed to exhibit a distinct type of spatial organization relative to contemporary urban systems. Here, we use the settlement scaling framework and properties of settlements recorded in systematic, full-coverage surveys to examine ways in which southern Mesoamerican settlement systems were both similar to and different from contemporary systems. We find that the population-area relationship in these settlements differs greatly from that reported for other agrarian settlement systems, but that more typical patterns emerge when one considers a site epicenter as the relevant social interaction area, and the population administered from a given center as the relevant interacting population. Our results imply that southern Mesoamerican populations mixed socially at a slower temporal rhythm than is typical of contemporary systems. Residential locations reflected the need to balance energetic and transport costs of farming with lower-frequency costs of commuting to central places. Nevertheless, increasing returns in activities such as civic construction were still realized through lower-frequency social mixing. These findings suggest that the primary difference between low-density urbanism and contemporary urban systems lies in the spatial and temporal rhythms of social mixing.
Introduction: eCTAS is a real time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The tool dynamically calculates a recommended CTAS score based on the presenting complaint, vital signs and selected clinical modifiers. The primary objective was to assess consistency of CTAS score distributions across 35 emergency departments (EDs) by 16 presenting complaints pre and post eCTAS implementation. Methods: This retrospective cohort study used population-based administrative data from January 2016 to December 2018 from all hospital EDs in Ontario that had implemented eCTAS with at least 9 months of data. Following a 3-month stabilization period, we compared data for 6 months post-eCTAS implementation to the same 6-month period the previous year (pre-implementation) to account for potential seasonal variation, patient volume and case-mix. We included triage encounters of adult (≥18 years) patients if they had one of 16 pre-specified high-volume, presenting complaints. A paired-samples t-test was used to determine consistency by estimating the absolute difference in CTAS distribution for each presenting complaint, by each hospital, pre and post eCTAS implementation, compared to the overall average of the 35 EDs. Results: There were 183,231 triage encounters in the pre-eCTAS cohort and 179,983 in the post-eCTAS cohort from 35 EDs across the province. Triage scores were more consistent with the overall average after eCTAS implementation in 6 (37.5%) presenting complaints: chest pain (cardiac features) (p < 0.001), extremity weakness/symptoms of cerebrovascular accident (p < 0.001), fever (p < 0.001), shortness of breath (p < 0.001), syncope (p = 0.02), and hyperglycemia (p = 0.03). Triage consistency was similar pre and post eCTAS implementation for the presenting complaints of altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication or vertigo. Conclusion: A standardized, electronic approach to performing triage assessments increased consistency in CTAS scores across many, but not all, high-volume CEDIS complaints. This does not reflect triage accuracy, as there are no known benchmarks for triage accuracy. Improvements in consistency were greatest for sentinel presenting complaints with a minimum allowable CTAS score.
There has been considerable interest internationally in the assessment and treatment of individuals who have a severe personality disorder and who might pose a high-risk of future recidivism. In the United Kingdom, the ‘Dangerous and Severe Personality Disorder’ (DSPD) programme was initiated to deal with just this group. It is important, however, that the DSPD service is filling a treatment void and not competing with already well-established and effective services for (non-DPSD) personality disordered patients. Objective: To establish whether those admitted to innovative DSPD services are different from those admitted to conventional personality disorder (PD) services.
To compare patients admitted to DSPD services with those admitted to personality disordered (non-DPSD) services.
Sixty patients admitted to DSPD services, under DSPD criteria, were compared with 44 patients admitted to personality disordered (non-DSPD) services within the same high secure psychiatric hospital, on risk measures, including
(1) an index of predicted future violence
(2) previous offending behaviour and
(3) pre-treatment levels of institutional risk-related behaviour.
DSPD patients do pose a greater clinical and management risk, have a higher number of pre-treatment risk-related behaviour, and have a greater number of convictions and imprisonments after age 18, relative to PD patients.
The findings broadly confirm the hypotheses as to the higher risk in DSPD patients and thus offer support for the main purpose of DSPD services: to provide treatment for those who represent the highest priority in terms of treatment need and risk to public protection. Implications are discussed.
The utility of questionnaire based self-report measures for non-clinical psychotic symptoms is unclear and there are few reliable data about the nature and prevalence of these phenomena in children. The study aimed to investigate psychosis-like symptoms (PLIKS) in children utilizing both self-report measures and semi-structured observer rated assessments.
The study was cross-sectional; the setting being an assessment clinic for members of the ALSPAC birth cohort in Bristol, UK. 6455 respondents were assessed over 21 months, mean age 12.9 years. The main outcome measure was: 12 self-report screening questions for psychotic symptoms followed by semi-structured observer rated assessments by trained psychology graduates. The assessment instrument utilised stem questions, glossary definitions, and rating rules adapted from DISC-IV and SCAN items.
The 6-month period prevalence for one or more PLIKS rated by self-report questions was 38.9 % (95% CI = 37.7-40.1). Prevalence using observer rated assessments was 13.7% (95% CI = 12.8-14.5). Positive Predictive Values for the screen questions versus observer rated scores were low, except for auditory hallucinations (PPV=70%; 95% CI = 67.1-74.2). The most frequent observer rated symptom was auditory hallucinations (7.3%); in 18.8% of these cases symptoms occurred weekly or more. The prevalence of DSM-IV ‘core’ schizophrenia symptoms was 3.62%. Rates were significantly higher in children with low socio-economic status.
With the exception of auditory hallucinations, self-rated questionnaires are likely to substantially over-estimate the frequency of PLIKS in 12-year-old children. However, more reliable observer rated assessments reveal that PLIKS occur in a significant proportion of children.
Abnormal brain connectivity has recently been reported in obsessive compulsive disorder (OCD). However, structural differences in the corpus callosum (CC), the primary structure connecting the two hemispheres, have not been extensively studied. In this case-control study, we recruited 30 patients with OCD and 30 healthy control subjects carefully matched for age, sex and handedness. Combining surface-based mesh-modeling and voxel-based morphometry (VBM), we compared callosal thickness and white matter (WM) density in patients and controls. We investigated associations between callosal structure and cortical gray matter (GM) density, and we related CC measures to neuropsychological performance in OCD. OCD patients showed small anterior and posterior callosal regions compared to healthy control subjects. In the OCD group, anterior callosal thickness was positively correlated with GM density of the right mid-dorso-lateral prefrontal (BA 9/46) area, while posterior callosal thickness was positively correlated with GM density in the left supramarginal gyrus (BA 40). Moreover, posterior callosal WM density was positively correlated with verbal memory, visuo-spatial memory, verbal fluency, and visuo-spatial reasoning performances. Callosal attributes were related to GM density in cortical areas innervated by the CC, and were also related to performance in cognitive domains impaired in the disorder. The CC may therefore be integrally involved in OCD.
Borderline personality disorder (BPD) is a chronic condition with a strong impact on patients’ affective, cognitive and social functioning. Neuroimaging techniques offer invaluable tools to understand the biological substrate of the disease. We aimed to investigate gray matter alterations over the whole cortex in a group of Borderline Personality Disorder (BPD) patients compared to healthy controls (HC).
Magnetic resonance-based cortical pattern matching was used to assess cortical gray matter density (GMD) in 26 BPD patients and in their age- and sex-matched HC (age: 38 ± 11; females: 16, 61%).
BPD patients showed widespread lower cortical GMD compared to HC (4% difference) with peaks of lower density located in the dorsal frontal cortex, in the orbitofrontal cortex, the anterior and posterior cingulate, the right parietal lobe, the temporal lobe (medial temporal cortex and fusiform gyrus) and in the visual cortex (P < 0.005). Our BPD subjects displayed a symmetric distribution of anomalies in the dorsal aspect of the cortical mantle, but a wider involvement of the left hemisphere in the mesial aspect in terms of lower density. A few restricted regions of higher density were detected in the right hemisphere. All regions remained significant after correction for multiple comparisons via permutation testing.
BPD patients feature specific morphology of the cerebral structures involved in cognitive and emotional processing and social cognition/mentalization, consistent with clinical and functional data.
There are increasing concerns regarding long-term psychotropic polypharmacy prescribed for foster care youth 3.5 to 5 times more often than in at-home youth (Kreider et al., 2014). Polypharmacy risks include weight gain, glucose intolerance and type 2 diabetes. (De Hert et al., 2011). In view of these risks, novel interventions are essential to safeguard foster care youth from overmedication.
To present guidelines for identification and management of polypharmacy in foster care youth.
To demonstrate a novel intervention to monitor and diminish polypharmacy and enhance psychiatric care in foster care children.
Polypharmacy is identified using LA County Juvenile Court Mental Health Service (JCMHS) Psychotropic Parameters* to review medication consent forms from treating psychiatrists. Polypharmacy triggers an in-person JCHMS consultation. *(Parameters 3.9 for JCMHS PMAF Review, Revised May 2015).
JCMHS Psychotropic Parameters (summary):
– age 0–5 years:
– 2 or > psychotropic medications,
– Any antipsychotic (*except Risperidone in ASD);
– age 6–8 years:
– 3 or > psychotropic medications;
– age 9–17 years:
– 4 or > psychotropic medications;
– All age youth:
– 2 or > psychotropic medications in the same class (antipsychotics, antidepressants, stimulants, mood stabilizers, alpha agonists).
Psychotropic medication doses in excess of recommended (*LA County Department of Mental Health Parameters 3.8 for use of Psychotropic Medications for Children and Adolescents).
Approximately 25% of JCMHS annual psychiatric consultations were initiated by JCMHS parameters for polypharmacy. Corresponding consultations included education and recommendations discussed with treating psychiatrists regarding polypharmacy and optimal psychiatric management.
JCMHS Psychotropic Parameters is a useful tool to identify polypharmacy and enhance psychiatric care of foster care youth.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
It is well known that youth in foster care are at high risk for psychiatric disorders, recently reported in up to 89%, with over 55% exhibiting ADHD in one sample (Linares et al., 2013). Psychotropic medication use was reported in 59% of foster care youth within a 2-month period (Brenner et al., 2013). The psychotropic medication consent process in Los Angeles for dependent children is multidisciplinary, starting with the treating psychiatrist's written authorization request to Children's Dependency Court. Once received, it is distributed to the child's attorney, social worker, and Juvenile Court Mental Health Service (JCMHS). JCMHS reviews and provides recommendations to the judicial officer who ultimately approves, modifies, or denies consent.
To present the steps and reasoning in the process of review, consultation, recommendations and decisions in psychotropic medication consent for dependent youth.
To provide an understanding of the multidisciplinary review process involved in determining psychotropic medication consent in foster care youth.
Presentation of a timeline, forms and guidelines used in the process including the “Psychotropic Medication Authorization Form” (PMA) (Judicial Council of California, 2008).
Categories of recommendations and approvals provided to the judicial officer will be presented and rationales for in-person consultations.
The psychotropic medication consent process for foster care youth is a complex multidisciplinary process which includes a clinically significant set of recommendations from JCMHS to the judicial officer to aid in making informed decisions regarding psychotropic medication.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Total laryngectomy is often utilised to manage squamous cell carcinoma of the larynx or hypopharynx. This study reports on surgical trends and outcomes over a 10-year period.
A retrospective review of patients undergoing total laryngectomy for squamous cell carcinoma was performed (n = 173), dividing patients into primary and salvage total laryngectomy cohorts.
A shift towards organ-sparing management was observed. Primary total laryngectomy was performed for locoregionally advanced disease and utilised reconstruction less than salvage total laryngectomy. Overall, 11 per cent of patients developed pharyngocutaneous fistulae (primary: 6 per cent; salvage: 20 per cent) and 11 per cent neopharyngeal stenosis (primary: 9 per cent; salvage: 15 per cent). Pharyngocutaneous fistulae rates were higher in the reconstructed primary total laryngectomy group (24 per cent; 4 of 17), compared with primary closure (3 per cent; 3 of 90) (p = 0.02). Patients were significantly more likely to develop neopharyngeal stenosis following pharyngocutaneous fistulae in salvage total laryngectomy (p = 0.01) and reconstruction in primary total laryngectomy (p = 0.02). Pre-operative haemoglobin level and adjuvant treatment failed to predict pharyngocutaneous fistulae development.
Complications remain hard to predict and there are continuing causes of morbidity. Additionally, prior treatment continues to affect surgical outcomes.
Tuberous sclerosis complex is a rare genetic disorder leading to the growth of hamartomas in multiple organs, including cardiac rhabdomyomas. Children with symptomatic cardiac rhabdomyoma require frequent admissions to intensive care units, have major complications, namely, arrhythmias, cardiac outflow tract obstruction and heart failure, affecting the quality of life and taking on high healthcare cost. Currently, there is no standard pharmacological treatment for this condition, and the management includes a conservative approach and supportive care. Everolimus has shown positive effects on subependymal giant cell astrocytomas, renal angiomyolipoma and refractory seizures associated with tuberous sclerosis complex. However, evidence supporting efficacy in symptomatic cardiac rhabdomyoma is limited to case reports. The ORACLE trial is the first randomised clinical trial assessing the efficacy of everolimus as a specific therapy for symptomatic cardiac rhabdomyoma.
ORACLE is a phase II, prospective, randomised, placebo-controlled, double-blind, multicentre protocol trial. A total of 40 children with symptomatic cardiac rhabdomyoma secondary to tuberous sclerosis complex will be randomised to receive oral everolimus or placebo for 3 months. The primary outcome is 50% or more reduction in the tumour size related to baseline. As secondary outcomes we include the presence of arrhythmias, pericardial effusion, intracardiac obstruction, adverse events, progression of tumour reduction and effect on heart failure.
ORACLE protocol addresses a relevant unmet need in children with tuberous sclerosis complex and cardiac rhabdomyoma. The results of the trial will potentially support the first evidence-based therapy for this condition.
Romanticism and realism are not diametrically opposed, and the history of the terms “romance” and “novel” reveal dialogical genre processes. Optative romanticism in Europe and America is in tension with negative romanticism. The principal American romance tradition is largely one of a dark romanticism, in which the gothic and grotesque merge with realism in the “romance-novel,” as in the fictions of Edgar Allan Poe, Nathaniel Hawthorne, Herman Melville, and later modernist and postmodernist writers. Four basic modes of Gothic can be identified ontologically as: indeterminate “historical” Gothic; determinate “rationalized” Gothic; determinate “supernatural” Gothic; indeterminate “equivocal” Gothic. The ambiguous fourth mode may involve questions of metaphysics, epistemological uncertainty, psychological instability, and textual indeterminacy. The fourth mode characterizes the fictions of Cormac McCarthy and Herman Melville – strikingly exemplified by the pervasive theme of “inscrutability” in Moby-Dick, McCarthy’s favorite book.
We sampled individual growth rings from three ancient remnant bald cypress (Taxodium distichum) trees from a massive buried deposit at the mouth of the Altamaha River on the Georgia Coast to determine the best technique for radiocarbon (14C) dating pretreatment. The results of our comparison of traditional ABA pretreatment and holocellulose and α-cellulose fractions show no significant differences among the pretreatments (<1 sigma) thereby suggesting that ABA pretreatment will prove sufficient for the development of a high-resolution 14C tree-ring chronology based on these ancient bald cypresses which will indicate whether the U.S. Southeast is subject to a regional radiocarbon offset.
Limpets and barnacles are important components of intertidal assemblages worldwide. This study examines the effects of barnacles on the foraging behaviour of the limpet Patella vulgata, which is the main algal grazer in the North-west Atlantic. The behaviour of limpets on a vertical seawall on the Isle of Man (UK) was investigated using autonomous radio-telemetry, comparing their activity patterns on plots characterized by dense barnacle cover and plots from which the barnacles had been removed. Limpet behaviour was investigated at mid-shore level, but two different elevations were considered. This experiment revealed a significant effect of barnacle cover on the activity of P. vulgata. Limpets on smooth surfaces spent a greater proportion of total time active than did limpets on barnacles. Movement activity was also greater in areas that were lower down in the tidal range. In general, limpets were either predominantly active during diurnal high or nocturnal low tides and always avoided nocturnal high tides. Individuals on barnacles at the higher elevation concentrated their activity during nocturnal low water. All the other groups of limpets (smooth surfaces on the upper level and all individuals on the lower shore) had more excursions centred around daylight hours with an equal distribution of activity between periods of low and high water. Inter-individual variability was, however, pronounced.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
Space Infrared Telescope for Cosmology and Astrophysics (SPICA), the cryogenic infrared space telescope recently pre-selected for a ‘Phase A’ concept study as one of the three remaining candidates for European Space Agency (ESA's) fifth medium class (M5) mission, is foreseen to include a far-infrared polarimetric imager [SPICA-POL, now called B-fields with BOlometers and Polarizers (B-BOP)], which would offer a unique opportunity to resolve major issues in our understanding of the nearby, cold magnetised Universe. This paper presents an overview of the main science drivers for B-BOP, including high dynamic range polarimetric imaging of the cold interstellar medium (ISM) in both our Milky Way and nearby galaxies. Thanks to a cooled telescope, B-BOP will deliver wide-field 100–350
m images of linearly polarised dust emission in Stokes Q and U with a resolution, signal-to-noise ratio, and both intensity and spatial dynamic ranges comparable to those achieved by Herschel images of the cold ISM in total intensity (Stokes I). The B-BOP 200
m images will also have a factor
30 higher resolution than Planck polarisation data. This will make B-BOP a unique tool for characterising the statistical properties of the magnetised ISM and probing the role of magnetic fields in the formation and evolution of the interstellar web of dusty molecular filaments giving birth to most stars in our Galaxy. B-BOP will also be a powerful instrument for studying the magnetism of nearby galaxies and testing Galactic dynamo models, constraining the physics of dust grain alignment, informing the problem of the interaction of cosmic rays with molecular clouds, tracing magnetic fields in the inner layers of protoplanetary disks, and monitoring accretion bursts in embedded protostars.
We aimed to provide comprehensive estimates of laboratory-confirmed respiratory syncytial virus (RSV)-associated hospitalisations. Between 2012 and 2015, active surveillance of acute respiratory infection (ARI) hospitalisations during winter seasons was used to estimate the seasonal incidence of laboratory-confirmed RSV hospitalisations in children aged <5 years in Auckland, New Zealand (NZ). Incidence rates were estimated by fine age group, ethnicity and socio-economic status (SES) strata. Additionally, RSV disease estimates determined through active surveillance were compared to rates estimated from hospital discharge codes. There were 5309 ARI hospitalisations among children during the study period, of which 3923 (73.9%) were tested for RSV and 1597 (40.7%) were RSV-positive. The seasonal incidence of RSV-associated ARI hospitalisations, once corrected for non-testing, was 6.1 (95% confidence intervals 5.8–6.4) per 1000 children <5 years old. The highest incidence was among children aged <3 months. Being of indigenous Māori or Pacific ethnicity or living in a neighbourhood with low SES independently increased the risk of an RSV-associated hospitalisation. RSV hospital discharge codes had a sensitivity of 71% for identifying laboratory-confirmed RSV cases. RSV infection is a leading cause of hospitalisation among children in NZ, with significant disparities by ethnicity and SES. Our findings highlight the need for effective RSV vaccines and therapies.