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Objectives: Individuals aged 90 or older (oldest-old), the fastest growing segment of the population, are at increased risk of developing cognitive impairment compared with younger old. Neuropsychological evaluation of the oldest-old is important yet challenging in part because of the scarcity of test norms for this group. We provide neuropsychological test norms for cognitively intact oldest-old. Methods: Test norms were derived from 403 cognitively intact participants of The 90+ Study, an ongoing study of aging and dementia in the oldest-old. Cognitive status of intact oldest-old was determined at baseline using cross-sectional approach. Individuals with cognitive impairment no dementia or dementia (according to DSM-IV criteria) were excluded. Participants ranged in age from 90 to 102 years (mean=94). The neuropsychological battery included 11 tests (Mini-Mental Status Examination, Modified Mini-Mental State Examination, Boston Naming Test – Short Form, Letter Fluency Test, Animal Fluency Test, California Verbal Learning Test-II Short Form, Trail Making Tests A/B/C, Digit Span Forward and Backwards Test, Clock Drawing Test, CERAD Construction Subtests), and the Geriatric Depression Scale. Results: Data show significantly lower scores with increasing age on most tests. Education level, sex, and symptoms of depression were associated with performance on several tests after accounting for age. Conclusions: Provided test norms will help to distinguish cognitively intact oldest-old from those with cognitive impairment. (JINS, 2019, 25, 530–545)
Soldier operational performance is determined by their fitness, nutritional status, quality of rest/recovery, and remaining injury/illness free. Understanding large fluctuations in nutritional status during operations is critical to safeguarding health and well-being. There are limited data world-wide describing the effect of extreme climate change on nutrient profiles. This study investigated the effect of hot-dry deployments on vitamin D status (assessed from 25-hydroxyvitamin D (25(OH)D) concentration) of young, male, military volunteers. Two data sets are presented (pilot study, n 37; main study, n 98), examining serum 25(OH)D concentrations before and during 6-month summer operational deployments to Afghanistan (March to October/November). Body mass, percentage of body fat, dietary intake and serum 25(OH)D concentrations were measured. In addition, parathyroid hormone (PTH), adjusted Ca and albumin concentrations were measured in the main study to better understand 25(OH)D fluctuations. Body mass and fat mass (FM) losses were greater for early (pre- to mid-) deployment compared with late (mid- to post-) deployment (P<0·05). Dietary intake was well-maintained despite high rates of energy expenditure. A pronounced increase in 25(OH)D was observed between pre- (March) and mid-deployment (June) (pilot study: 51 (sd 20) v. 212 (sd 85) nmol/l, P<0·05; main study: 55 (sd 22) v. 167 (sd 71) nmol/l, P<0·05) and remained elevated post-deployment (October/November). In contrast, PTH was highest pre-deployment, decreasing thereafter (main study: 4·45 (sd 2·20) v. 3·79 (sd 1·50) pmol/l, P<0·05). The typical seasonal cycling of vitamin D appeared exaggerated in this active male population undertaking an arduous summer deployment. Further research is warranted, where such large seasonal vitamin D fluctuations may be detrimental to bone health in the longer-term.
The modern arrangement of the texts of plays evolved from the confluence of two distinct methods of setting out plays for readers and theatrical use. The earliest, which I shall call the native tradition, had its seeds in the European liturgical drama and is most clearly manifested in the manuscripts of the early moral plays and of guild plays associated with Corpus Christi from the fourteenth century to the cessation of the performances late in the sixteenth century. The second is the classical method, exemplified by the early printings of the plays of Terence, Plautus, and Seneca from 1470 onwards and adopted by the university educated writers of secular plays in the sixteenth century.
Introduction: Unnecessary care is an increasingly commonly used term in medicine. Previous survey research suggests that definitions of unnecessary care vary within and among professional and patient groups. This research explores how emergency physicians and administrators understand the term unnecessary care. Methods: Site chiefs and emergency physicians in an Alberta region were recruited through email and online surveys respectively for a qualitative study. One hour one-on-one in-depth interviews explored understandings of unnecessary care within the emergency department (ED) context. Interview transcripts underwent thematic analysis. Results: Five physicians and seven site chiefs completed interviews. Two key themes emerged. First, interviewees conceptualized unnecessary care as inappropriate or non-urgent presentations. This patient-centric view raised non-urgent ED presentations as a health system problem with complex components, including: lack of public knowledge of healthcare resources, shrinking comfort and scope of community providers and patient willingness to utilize other resources. Despite concerns over non-urgent visits, interviewees expressed that these patients still need to be seen, assessed and managed. The second conceptualization focused on over-investigation (and to lesser extent, treatment). This physician-centric conceptualization identified issues around: variation in physician risk tolerance, established decision rules with the allowable miss rates, patient expectation for testing or physician feeling that the patient was owed something or that patient would not accept their diagnosis/treatment without testing. Additionally, interviewees described patient characteristics that may initiate more aggressive investigation (e.g., patient reliability, follow-up care access, etc.). An overarching concern about the connection between unnecessary care and wasted resources was identified. Additionally, interviewees emphasized that patient conversations are outside the scope of unnecessary care despite their possible implications for limited time resources. Conclusion: A range of concepts surrounding unnecessary care in the ED were identified. Further exploring nuances of these conceptualizations may inform and improve the effectiveness of campaigns seeking to improve efficiency in practice and reduce inappropriate care. Additionally, this work provides an impetus for developing clearer concepts of care within the ED.
Recent findings highlight that there are prenatal risks for affective disorders that are mediated by glucocorticoid mechanisms, and may be specific to females. There is also evidence of sex differences in prenatal programming mechanisms and developmental psychopathology, whereby effects are in opposite directions in males and females. As birth weight is a risk for affective disorders, we sought to investigate whether maternal prenatal cortisol may have sex-specific effects on fetal growth. Participants were 241 mothers selected from the Wirral Child Health and Development Study (WCHADS) cohort (n=1233) using a psychosocial risk stratifier, so that responses could be weighted back to the general population. Mothers provided saliva samples, which were assayed for cortisol, at home over 2 days at 32 weeks gestation (on waking, 30-min post-waking and during the evening). Measures of infant birth weight (corrected for gestational age) were taken from hospital records. General population estimates of associations between variables were obtained using inverse probability weights. Maternal log of the area under the curve cortisol predicted infant birth weight in a sex-dependent manner (interaction term P=0.029). There was a positive and statistically significant association between prenatal cortisol in males, and a negative association in females that was not statistically significant. A sex interaction in the same direction was evident when using the waking (P=0.015), and 30-min post-waking (P=0.013) cortisol, but not the evening measure. There was no interaction between prenatal cortisol and sex to predict gestational age. Our findings add to an emerging literature that suggests that there may be sex-specific mechanisms that underpin fetal programming.
A combination of better management and genetic selection for good health and fertility would provide a more effective long term solution for economic loss due to diseases and poor fertility. This would also help to address public concerns about the use of medical treatment in milk production. A balance in the genetic improvement of health and fertility together with milk production could be achieved through their inclusion in national genetic selection indices, for which genetic parameters are needed. One of the main objectives of this study was to estimate genetic parameters for various disease and fertility traits in the UK dairy cattle population, using records from a national recording scheme run by Livestock Services UK Ltd. Genetic analysis of traits recorded as present or absent (binary traits; e.g. diseases) requires the use of non-linear threshold models, because linear models require normality assumptions (e.g., Gianola 1982). The other objective of this study was to estimate genetic parameters for binary disease and fertility traits based on threshold animal models and to compare results with those from linear animal models.
Rapid diagnostic technologies can assist Antimicrobial Stewardship Programs (ASPs) in achieving the goals of reducing unnecessary antimicrobial exposure and optimizing patient care. The Society of Infectious Diseases Pharmacists supports all members of the ASP team as essential components of optimal use of these technologies for management of antibiotic prescribing and cost-reduction strategies.
Vulnerability of satellite-based navigation signals to intentional and unintentional interference calls for a high-level overview of Global Navigation Satellite System (GNSS) threats occurring globally to understand the magnitude and evolution of the problem. Therefore, a mechanism needs to be developed whereby disparate monitoring systems will be capable of contributing to a common entity of basic information about the threat scenarios they experience. This paper begins with a literature survey of 37 state-of-the-art GNSS threat monitoring systems, which have been analysed based on their respective operational features - constellations monitored and whether they possess the capability to perform interference-type classification, spoofing detection, and interference localisation. Also described is a comparative analysis of four GNSS threat reporting formats in use today. Based on these studies, the paper describes the Horizon2020 Standardisation of GNSS Threat Reporting and Receiver Testing through International Knowledge Exchange, Experimentation and Exploitation (STRIKE3) proposed integrated threat monitoring demonstration system and related standardised threat reporting message, to enable a high-level overview of the prevailing international GNSS threat scenarios and its evolution over time.
Tail docking of new born lambs is a routine practice in the United Kingdom. It has been used as a strategy to reduce the impact of myriasis (blowfly strike). There is only a limited period of time after birth (up to seven days) during which lambs can be docked without the use of anaethesia. Tail docking may have a detrimental effect on the ewe-lamb bond if the process leads to significant and sustained pain. French, Wall and Morgan (1994) suggested lambs suffer acute pain immediately after the procedure of docking but this potential disturbance of normal behaviour during the first few days of life did not seem to affect the long-term performance of lambs. The study reported in this paper considers the effect of tail docking on the behaviour of lambs during the first 90 minutes after docking and on lamb performance to slaughter.
The fine structure of the acoustic and gravity mode multiplets of the Sun have been analyzed to infer the internal rotation of the Sun and upper limits of the internal magnetic field. Observed fine structure for 137 multiplets has been obtained (Hill 1984b, 1985a, 1985b) and the fine structure has been examined for dependence on the angular order, m, of the modes. The inferred angular velocity distribution, together with the estimated upper limits on the internal magnetic fields, yields a gravitational quadrupole moment, J2, of ≈7.7 × 10−6. This result is consistent with the result obtained by Hill, Bos and Goode (1982) and has important implications for planetary tests of theories of gravitation.
A photometric solar seismograph, as part of an international network, was installed at Yunnan Observatory, the Chinese Academy of Sciences, and put into operation in the spring of 1991. This instrument is used to detect solar oscillations by measuring the continuum radiation intensity on the solar disk with a spatial resolution of 50 arcsec, in heliocentric coordinates, for research on p-modes and g-modes when l < 50, where l is the angular degree of the eigenfunction. The solar oscillations can be observed simultaneously at two wavelengths of the detector with a sensitivity of 10 of the average intensity. This paper reports on the optical system of the instrument. Also introduced in this paper is the compensation system for the noise signals produced by the changes in the transparency of the Earth's atmosphere. This is based on solar photometry at wavelengths of 0.55 mm and 1.6 mm.
The Great Christian Jurists series comprises a library of national volumes of detailed biographies of leading jurists, judges and practitioners, assessing the impact of their Christian faith on the professional output of the individuals studied. Little has previously been written about the faith of the great judges who framed and developed the English common law over centuries, but this unique volume explores how their beliefs were reflected in their judicial functions. This comparative study, embracing ten centuries of English law, draws some remarkable conclusions as to how Christianity shaped the views of lawyers and judges. Adopting a long historical perspective, this volume also explores the lives of judges whose practice in or conception of law helped to shape the Church, its law or the articulation of its doctrine.
A simple, portable capillary refill time (CRT) simulator is not commercially available. This device would be useful in mass-casualty simulations with multiple volunteers or mannequins depicting a variety of clinical findings and CRTs. The objective of this study was to develop and evaluate a prototype CRT simulator in a disaster simulation context.
A CRT prototype simulator was developed by embedding a pressure-sensitive piezo crystal, and a single red light-emitting diode (LED) light was embedded, within a flesh-toned resin. The LED light was programmed to turn white proportionate to the pressure applied, and gradually to return to red on release. The time to color return was adjustable with an external dial. The prototype was tested for feasibility among two cohorts: emergency medicine physicians in a tabletop exercise and second year medical students within an actual disaster triage drill. The realism of the simulator was compared to video-based CRT, and participants used a Visual Analog Scale (VAS) ranging from “completely artificial” to “as if on a real patient.” The VAS evaluated both the visual realism and the functional (eg, tactile) realism. Accuracy of CRT was evaluated only by the physician cohort. Data were analyzed using parametric and non-parametric statistics, and mean Cohen’s Kappas were used to describe inter-rater reliability.
The CRT simulator was generally well received by the participants. The simulator was perceived to have slightly higher functional realism (P=.06, P=.01) but lower visual realism (P=.002, P=.11) than the video-based CRT. Emergency medicine physicians had higher accuracy on portrayed CRT on the simulator than the videos (92.6% versus 71.1%; P<.001). Inter-rater reliability was higher for the simulator (0.78 versus 0.27; P<.001).
A simple, LED-based CRT simulator was well received in both settings. Prior to widespread use for disaster triage training, validation on participants’ ability to accurately triage disaster victims using CRT simulators and video-based CRT simulations should be performed.
ChangTP, SantillanesG, Claudius I, PhamPK, KovedJ, CheyneJ, Gausche-HillM, KajiAH, SrinivasanS, DonofrioJJ, BirC. Use of a Novel, Portable, LED-Based Capillary Refill Time Simulator within a Disaster Triage Context. Prehosp Disaster Med. 2017;32(4):451–456.