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Subspecialisation is increasingly a fundamental part of the contemporary practice of medicine. However, little is known about how medical trainees learn in the modern era, and particularly in growing and relatively new subspecialties, such as adult CHD. The purpose of this study was to assess institutional-led and self-directed learning strategies of adult CHD fellows.
This international, cross-sectional online survey was conducted by the International Society for Adult Congenital Heart Disease and consisted primarily of categorical questions and Likert rating scales. All current or recent (i.e., those within 2 years of training) fellows who reported training in adult CHD (within adult/paediatric cardiology training or within subspecialty fellowships) were eligible.
A total of 75 fellows participated in the survey: mean age: 34 ± 5; 35 (47%) female. Most adult CHD subspecialty fellows considered case-based teaching (58%) as “very helpful”, while topic-based teaching was considered “helpful” (67%); p = 0.003 (favouring case-based). When facing a non-urgent clinical dilemma, fellows reported that they were more likely to search for information online (58%) than consult a faculty member (29%) or textbook (3%). Many (69%) fellows use their smartphones at least once daily to search for information during regular clinical work.
Fellows receiving adult CHD training reported a preference for case-based learning and frequent use of online material and smartphones. These findings may be incorporated into the design and enhancement of fellowships and development of online training resources.
Compulsory admission is commonly regarded as necessary and justified for patients whose psychiatric condition represents a severe danger to themselves and others. However, while studies on compulsory admissions have reported on various clinical and social outcomes, little research has focused specifically on dangerousness, which in many countries is the core reason for compulsory admission.
To study changes in dangerousness over time in adult psychiatric patients admitted by compulsory court order, and to relate these changes to these patients' demographic and clinical characteristics.
In this explorative prospective observational cohort study of adult psychiatric patients admitted by compulsory court order, demographic and clinical data were collected at baseline. At baseline and at 6 and 12 month follow-up, dangerousness was assessed using the Dangerousness Inventory, an instrument based on the eight types of dangerousness towards self or others specified in Dutch legislation on compulsory admissions. We used descriptive statistics and logistic regression to analyse the data.
We included 174 participants with a court-ordered compulsory admission. At baseline, the most common dangerousness criterion was inability to cope in society. Any type of severe or very severe dangerousness decreased from 86.2% at baseline to 36.2% at 6 months and to 28.7% at 12 months. Being homeless at baseline was the only variable which was significantly associated with persistently high levels of dangerousness.
Dangerousness decreased in about two-thirds of the patients after court-ordered compulsory admission. It persisted, however, in a substantial minority (approximately one-third).
The role of diet on breast cancer risk is not well elucidated but animal food sources may play a role through, for example, the pathway of the insulin-like growth factor 1 system or cholesterol metabolism. The aim of this study was to evaluate the association between animal foods and the risk of postmenopausal breast cancer. This study was embedded in the Rotterdam Study, a population-based prospective cohort study of subjects aged 55 years and over (61 % female). Dietary intake of different animal foods was assessed at baseline using a validated FFQ and adjusted for energy intake using the residual method. We performed Cox proportional hazards modelling to analyse the association between the intake of the different food sources and breast cancer risk after adjustment for socio-demographic, lifestyle and metabolic factors. During a median follow-up of 17 years, we identified 199 cases of breast cancer (6·2 %) among 3209 women. After adjustment for multiple confounders, no consistent association was found between the intake of red meat intake, poultry, fish or dairy products and breast cancer risk. However, we found that egg intake was significantly associated with a higher risk of breast cancer (hazard ratioQ4 v. Q1: 1·83; 95 % CI 1·20, 2·79; Ptrend=0·01). In conclusion, this study found that dietary egg intake but no other animal foods was associated with a higher risk of postmenopausal breast cancer. Further research on the potential mechanisms underlying this association is warranted.
To investigate the effects of friendly competition on hand hygiene compliance as part of a multimodal intervention program.
Prospective observational study in which the primary outcome was hand hygiene compliance. Differences were analyzed using the Pearson χ2 test. Odds ratios (ORs) with 95% confidence interval were calculated using multilevel logistic regression.
Observations were performed in 9 public hospitals and 1 rehabilitation center in Rotterdam, Netherlands.
From 2014 to 2016, at 5 time points (at 6-month intervals) in 120 hospital wards, 20,286 hand hygiene opportunities were observed among physicians, nurses, and other healthcare workers (HCWs).
The multimodal, friendly competition intervention consisted of mandatory interventions: monitoring and feedback of hand hygiene compliance and optional interventions (ie, e-learning, kick-off workshop, observer training, and team training). Hand hygiene opportunities, as formulated by the World Health Organization (WHO), were unobtrusively observed at 5 time points by trained observers. Compliance data were presented to the healthcare organizations as a ranking.
The overall mean hand hygiene compliance at time point 1 was 42.9% (95% confidence interval [CI], 41.4–44.4), which increased to 51.4% (95% CI, 49.8–53.0) at time point 5 (P<.001). Nurses showed a significant improvement between time points 1 and 5 (P<.001), whereas the compliance of physicians and other HCWs remained unchanged. In the multilevel logistic regressions, time points, type of ward, and type of HCW showed a significant association with compliance.
Between the start and the end of the multimodal intervention program in a friendly competition setting, overall hand hygiene compliance increased significantly.
It is well known that deterministic two-dimensional marine ice sheets can only be stable if the grounding line is positioned at a sufficiently steep, downward sloping bedrock. When bedrock conditions favour instabilities, multiple stable ice sheet profiles may occur. Here, we employ continuation techniques to examine the sensitivity of a two-dimensional marine ice sheet to stochastic noise representing short time scale variability, either in the accumulation rate or in the sea level height. We find that in unique regimes, the position of the grounding line is most sensitive to noise in the accumulation rate and can explain excursions observed in field measurements. In the multiple equilibrium regime, there is a strong asymmetry in transition probabilities between the different ice sheet states, with a strong preference to switch to the branch with a steeper bedrock slope.
Personality disorders commonly coexist with alcohol use disorders (AUDs), but there is conflicting evidence on their association with treatment outcomes.
To determine the size and direction of the association between personality disorder and the outcome of treatment for AUD.
We conducted a systematic review and meta-analysis of randomised trials and longitudinal studies.
Personality disorders were associated with more alcohol-related impairment at baseline and less retention in treatment. However, during follow-up people with a personality disorder showed a similar amount of improvement in alcohol outcomes to that of people without such disorder. Synthesis of evidence was hampered by variable outcome reporting and a low quality of evidence overall.
Current evidence suggests the pessimism about treatment outcomes for this group of patients may be unfounded. However, there is an urgent need for more consistent and better quality reporting of outcomes in future studies in this area.
Estimating the risk of a complicated course of Clostridium difficile infection (CDI) might help doctors guide treatment. We aimed to validate 3 published prediction models: Hensgens (2014), Na (2015), and Welfare (2011).
The validation cohort comprised 148 patients diagnosed with CDI between May 2013 and March 2014. During this period, 70 endemic cases of CDI occurred as well as 78 cases of CDI related to an outbreak of C. difficile ribotype 027. Model calibration and discrimination were assessed for the 3 prediction rules.
A complicated course (ie, death, colectomy, or ICU admission due to CDI) was observed in 31 patients (21%), and 23 patients (16%) died within 30 days of CDI diagnosis. The performance of all 3 prediction models was poor when applied to the total validation cohort with an estimated area under the curve (AUC) of 0.68 for the Hensgens model, 0.54 for the Na model, and 0.61 for the Welfare model. For those patients diagnosed with CDI due to non-outbreak strains, the prediction model developed by Hensgens performed the best, with an AUC of 0.78.
All 3 prediction models performed poorly when using our total cohort, which included CDI cases from an outbreak as well as endemic cases. The prediction model of Hensgens performed relatively well for patients diagnosed with CDI due to non-outbreak strains, and this model may be useful in endemic settings.
The parent–child attachment relationship plays an important role in the development of the infant's stress regulation system. However, genetic and epigenetic factors such as FK506 binding protein 51 (FKBP5) genotype and DNA methylation have also been associated with hypothalamus–pituitary–adrenal axis functioning. In the current study, we examined how parent–child dyadic regulation works in concert with genetic and epigenetic aspects of stress regulation. We study the associations of attachment, extreme maternal insensitivity, FKBP5 single nucleotide polymorphism 1360780, and FKBP5 methylation, with cortisol reactivity to the Strange Situation Procedure in 298 14-month-old infants. The results indicate that FKBP5 methylation moderates the associations of FKBP5 genotype and resistant attachment with cortisol reactivity. We conclude that the inclusion of epigenetics in the field of developmental psychopathology may lead to a more precise picture of the interplay between genetic makeup and parenting in shaping stress reactivity.
Depression is associated with the metabolic syndrome (MS). We examined whether metabolic dysregulation predicted the 2-year course of clinical depression.
A total of 285 older persons (⩾60 years) suffering from depressive disorder according to DSM-IV-TR criteria was followed up for 2 years. Severity of depression was assessed with the Inventory of Depressive Symptomatology (IDS) at 6-month intervals. Metabolic syndrome was defined according the National Cholesterol Education Programme (NCEP-ATP III). We applied logistic regression and linear mixed models adjusted for age, sex, years of education, smoking, alcohol use, physical activity, somatic co-morbidity, cognitive functioning and drug use (antidepressants, anti-inflammatory drugs) and severity of depression at baseline.
MS predicted non-remission at 2 years (odds ratioper component = 1.26, 95% confidence interval 1.00–1.58), p = 0.047), which was driven by the waist circumference and HDL cholesterol. MS was not associated with IDS sum score. Subsequent analyses on its subscales, however, identified an association with the somatic symptom subscale score over time (interaction time × somatic subscale, p = 0.005), driven by higher waist circumference and elevated fasting glucose level.
Metabolic dysregulation predicts a poor course of late-life depression. This finding supports the concept of ‘metabolic depression’, recently proposed on population-based findings of a protracted course of depressive symptoms in the presence of metabolic dysregulation. Our findings seem to be driven by abdominal obesity (as indicated by the waist circumference) and HDL cholesterol dysregulation.
At the first meeting of the newly formed Commission on Spectrophotometry, at Paris in 1935, a thorough discussion, aided by several reports, took place on the principles of this branch of astrophysics. So it will be sufficient now to treat only such special points of theory and practice as have won interest by researches of the last few years.
The rise of Holocene (ground)water level as a function of relative sea-level rise has been extensively investigated in the western Netherlands, whereas few studies focused on the Flevo lagoon in the central Netherlands. In this study, all available 14C dates from the base of basal peat overlying the top of compaction-free Pleistocene sand in the former Flevo lagoon were evaluated in order to reconstruct water-level rise for the period 5300-2000 cal. yr BC. The present basal peat 14C data set from Flevoland consists of two subsets: (1) the largely new Almere data (41 dates) representing the southern part of the former Flevo lagoon, with 26 dates especially carried out for this study, and (2) the existing Schokland data (21 dates) representing the eastern part of the lagoon. The Schokland area is located about 50 km from the Almere area. The quality of all basal peat time-depth data was palaeo-ecologically and geologically evaluated, all 14C dates were calibrated to the same standards, and error margins of age and altitude determination were estimated. After plotting the data as error boxes in time-depth graphs, lower limit curves for water-level rise were constructed for both data sets. Comparison with the mean sea-level curve for The Netherlands (Van de Plassche, 1982) suggests that water-level rise in the Almere area between 5300 and 2000 cal. yr BC corresponded closely to the rise in mean sea level. The same holds for the Schokland area for the period 5000-4200 cal. yr BC. For the period 4200-2000 cal. yr BC, however, the Schokland data suggest water-level rise to have been slower than mean sea-level rise, leading to local water levels apparently below mean sea level, which is virtually impossible. Hypothetical explanations for this discrepancy include: errors and uncertainties in mean sea-level and local water-level reconstruction, basin subsidence and temporal differences in intra-coastal tidal damping. The presently available data are inconclusive at this point and Holocene water-level rise in the Flevo lagoon awaits further investigations.
Breeding programmes for livestock require economic weights for traits that reflect the most profitable animal in a given production system, which affect the response in each trait after selection. The profitability of sheep production systems is affected by changes in pasture growth as well as grain, meat and wool prices between seasons and across years. Annual pasture growth varies between regions within Australia’s Mediterranean climate zone from low growth with long periods of drought to high growth with shorter periods of drought. Therefore, the objective of this study was to assess whether breeding objectives need to be adapted for regions, depending on how reliable the pasture growth is across years. We modelled farms with Merino sheep bred for wool and meat in 10 regions in Western Australia. Across these 10 regions, mean annual pasture growth decreased, and the CV of annual pasture growth increased as pasture growth for regions became less reliable. We calculated economic values for nine traits, optimising management across 11 years, including variation for pasture growth and wool, meat and grain prices between and within years from 2002 to 2012. These economic values were used to calculate responses to selection for each trait for the 10 regions. We identified two potential breeding objectives, one for regions with low or high reliability and the other for regions with medium reliability of pasture growth. Breeding objectives for high or low pasture growth reliability had more emphasis on live weight traits and number of lambs weaned. Breeding objectives for medium reliability of pasture growth had more emphasis on decreasing fibre diameter. Relative economic weights for fleece weight did not change across the regions. Regions with low or high pasture reliability had similar breeding objectives and response to selection, because the relationship between the economic values and CV of pasture growth were not linear for live weight traits and the number of lambs weaned. This non-linearity was caused by differences in distribution of pasture growth between regions, particularly during summer and autumn, when ewes were pregnant, with increases in energy requirements affecting the value of lambs weaned. In addition, increasing live weight increased the intake capacity of sheep, which meant that more poor quality pasture could be consumed during summer and autumn, which had more value in regions with low and high pasture reliability. We concluded that breeding values for sheep production systems should be customised depending on the reliability of pasture growth between years.
There is evidence for health benefits from ‘Palaeolithic’ diets; however, there are a few data on the acute effects of rationally designed Palaeolithic-type meals. In the present study, we used Palaeolithic diet principles to construct meals comprising readily available ingredients: fish and a variety of plants, selected to be rich in fibre and phyto-nutrients. We investigated the acute effects of two Palaeolithic-type meals (PAL 1 and PAL 2) and a reference meal based on WHO guidelines (REF), on blood glucose control, gut hormone responses and appetite regulation. Using a randomised cross-over trial design, healthy subjects were given three meals on separate occasions. PAL2 and REF were matched for energy, protein, fat and carbohydrates; PAL1 contained more protein and energy. Plasma glucose, insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide (GIP) and peptide YY (PYY) concentrations were measured over a period of 180 min. Satiation was assessed using electronic visual analogue scale (EVAS) scores. GLP-1 and PYY concentrations were significantly increased across 180 min for both PAL1 (P= 0·001 and P< 0·001) and PAL2 (P= 0·011 and P= 0·003) compared with the REF. Concomitant EVAS scores showed increased satiety. By contrast, GIP concentration was significantly suppressed. Positive incremental AUC over 120 min for glucose and insulin did not differ between the meals. Consumption of meals based on Palaeolithic diet principles resulted in significant increases in incretin and anorectic gut hormones and increased perceived satiety. Surprisingly, this was independent of the energy or protein content of the meal and therefore suggests potential benefits for reduced risk of obesity.
To create a system for the uniform registration and classification of complications and failures in cochlear implant surgery, and apply it to all the patients who underwent implantation in our clinic.
The definition of a medical complication was established, and data for all cochlear implantations performed between 1987 and 2012 were entered into a custom-made database system.
One or more medical complications were registered in 19.0 per cent of 1003 cochlear implantations. The incidence of ‘hard failure’ was 2.3 per cent. Findings revealed a decrease in device failures over the years; the rate of medical complications remained constant.
Our database system, which is available free of charge, enables fast and accurate data entry. There were a relatively high number of (minor) complications in our series, but comparison with the relevant literature is difficult. This emphasises the need for a uniform definition of ‘complication’ as it relates to cochlear implant surgery, and an appropriate classification system for such complications.
In livestock, many studies have reported the results of imputation to 50k single nucleotide polymorphism (SNP) genotypes for animals that are genotyped with low-density SNP panels. The objective of this paper is to review different measures of correctness of imputation, and to evaluate their utility depending on the purpose of the imputed genotypes. Across studies, imputation accuracy, computed as the correlation between true and imputed genotypes, and imputation error rates, that counts the number of incorrectly imputed alleles, are commonly used measures of imputation correctness. Based on the nature of both measures and results reported in the literature, imputation accuracy appears to be a more useful measure of the correctness of imputation than imputation error rates, because imputation accuracy does not depend on minor allele frequency (MAF), whereas imputation error rate depends on MAF. Therefore imputation accuracy can be better compared across loci with different MAF. Imputation accuracy depends on the ability of identifying the correct haplotype of a SNP, but many other factors have been identified as well, including the number of genotyped immediate ancestors, the number of animals with genotypes at the high-density panel, the SNP density on the low- and high-density panel, the MAF of the imputed SNP and whether imputed SNP are located at the end of a chromosome or not. Some of these factors directly contribute to the linkage disequilibrium between imputed SNP and SNP on the low-density panel. When imputation accuracy is assessed as a predictor for the accuracy of subsequent genomic prediction, we recommend that: (1) individual-specific imputation accuracies should be used that are computed after centring and scaling both true and imputed genotypes; and (2) imputation of gene dosage is preferred over imputation of the most likely genotype, as this increases accuracy and reduces bias of the imputed genotypes and the subsequent genomic predictions.
This study aimed to identify genetic evaluation models (GEM) to accurately select cattle for milk production when only limited data are available. It is based on a data set from the Pakistani Sahiwal progeny testing programme which includes records from five government herds, each consisting of 100 to 350 animals, with lactation records dating back to 1968. Different types of GEM were compared, namely: (1) multivariate v. repeatability model when using the first three lactations, (2) an animal v. a sire model, (3) different fixed effects models to account for effects such as herd, year and season; and (4) fitting a model with genetic parameters fixed v. estimating the genetic parameters as part of the model fitting process. Two methods were used for the comparison of models. The first method used simulated data based on the Pakistani progeny testing system and compared estimated breeding values with true breeding values. The second method used cross-validation to determine the best model in subsets of actual Australian herd-recorded data. Subsets were chosen to reflect the Pakistani data in terms of herd size and number of herds. Based on the simulation and the cross-validation method, the multivariate animal model using fixed genetic parameters was generally the superior GEM, but problems arise in determining suitable values for fixing the parameters. Using mean square error of prediction, the best fixed effects structure could not be conclusively determined. The simulation method indicated the simplest fixed effects structure to be superior whereas in contrast, the cross-validation method on actual data concluded that the most complex one was the best. In conclusion it is difficult to propose a universally best GEM that can be used in any data set of this size. However, some general recommendations are that it is more appropriate to estimate the genetic parameters when evaluating for selection purposes, the animal model was superior to the sire model and that in the Pakistani situation the repeatability model is more suitable than a multivariate.
We investigated the extent to which the geographic proximity of adult children affected the relocations of older people in the Netherlands in 2008. A major contribution of this study is the examination of the differentiation between relocation to care institutions and elsewhere. Data from the Dutch population register linked to complementary datasets were analysed for nearly one million inhabitants aged 75 and above, using multinomial logistic regression models to estimate the effects of intergenerational proximity and of other factors on the propensity to relocate to an institution and elsewhere. An interaction of proximity with partnership status as an indicator of the presence of an important care provider was considered. We found that older people were less likely to move elsewhere when their children were living very close by, and were more likely to do so when their children were living farther away. Having children living close was negatively associated with the likelihood of moving to a care institution. Very close proximity had an additional negative effect on the propensity of older people with a partner to relocate elsewhere whereas the negative effect was less for older people without a partner on moving elsewhere. Our findings did, however, show that (recently) widowed people were more likely to move elsewhere when their children were living more than 40 kilometres away.
This work was part of the EU RobustMilk project. In this work package, we have focused on two aspects of robustness, micro- and macro-environmental sensitivity and applied these to somatic cell count (SCC), one aspect of milk quality. We showed that it is possible to combine both categorical and continuous descriptions of the environment in one analysis of genotype by environment interaction. We also developed a method to estimate genetic variation in residual variance and applied it to both simulated and a large field data set of dairy cattle. We showed that it is possible to estimate genetic variation in both micro- and macro-environmental sensitivity in the same data, but that there is a need for good data structure. In a dairy cattle example, this would mean at least 100 bulls with at least 100 daughters each. We also developed methods for improved genetic evaluation of SCC. We estimated genetic variance for some alternative SCC traits, both in an experimental herd data and in field data. Most of them were highly correlated with subclinical mastitis (>0.9) and clinical mastitis (0.7 to 0.8), and were also highly correlated with each other. We studied whether the fact that animals in different herds are differentially exposed to mastitis pathogens could be a reason for the low heritabilities for mastitis, but did not find strong evidence for that. We also created a new model to estimate breeding values not only for the probability of getting mastitis but also for recovering from it. In a progeny-testing situation, this approach resulted in accuracies of 0.75 and 0.4 for these two traits, respectively, which means that it is possible to also select for cows that recover more quickly if they get mastitis.