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Healthy older adults typically retain high functioning in the social realm. Nevertheless, social networks, social support, and qualities of relationships vary in late life. This chapter addresses three questions: (1) What areas of cognitive functioning are associated with the social realm? (2) What mechanisms account for these associations? (3) Do these patterns extend to pathological declines associated with dementia? Individuals with a diversity of social partners retain general cognitive functioning more so than individuals with a limited set of social partners. Social integration provides stimulation and activities, and mitigates negative emotion in ways that contribute to cognitive health. Findings suggest that social ties cannot deter pathological declines associated with dementia. In sum, a wide range of social partners appears to be one of multiple resources (e.g., higher socioeconomic status, better locus of control, better health behaviors) that help maintain cognitive functioning in late life.
Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures & Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.
Computer-assisted navigation (CAN) improves the accuracy of spinal instrumentation in vertebral fractures and degenerative spine disease; however, it is not widely adopted because of lack of training, high capital costs, workflow hindrances, and accuracy concerns. We characterize shifts in the use of spinal CAN over time and across disciplines in a single-payer health system, and assess the impact of intra-operative CAN on trainee proficiency across Canada.
A prospectively maintained Ontario database of patients undergoing spinal instrumentation from 2005 to 2014 was reviewed retrospectively. Data were collected on treated pathology, spine region, surgical approach, institution type, and surgeon specialty. Trainee proficiency with CAN was assessed using an electronic questionnaire distributed across 15 Canadian orthopedic surgical and neurosurgical programs.
In our provincial cohort, 16.8% of instrumented fusions were CAN-guided. Navigation was used more frequently in academic institutions (15.9% vs. 12.3%, p<0.001) and by neurosurgeons than orthopedic surgeons (21.0% vs. 12.4%, p<0.001). Of residents and fellows 34.1% were fully comfortable using spinal CAN, greater for neurosurgical than orthopedic surgical trainees (48.1% vs. 11.8%, p=0.008). The use of CAN increased self-reported proficiency in thoracic instrumentation for all trainees by 11.0% (p=0.036), and in atlantoaxial instrumentation for orthopedic trainees by 18.0% (p=0.014).
Spinal CAN is used most frequently by neurosurgeons and in academic centers. Most spine surgical trainees are not fully comfortable with the use of CAN, but report an increase in technical comfort with CAN guidance particularly for thoracic instrumentation. Increased education in spinal CAN for trainees, particularly at the fellowship stage and, specifically, for orthopedic surgery, may improve adoption.
Evidence of cerebral degeneration is not apparent on routine brain MRI in amyotrophic lateral sclerosis (ALS). Texture analysis can detect change in images based on the statistical properties of voxel intensities. Our objective was to test the utility of texture analysis in detecting cerebral degeneration in ALS. A secondary objective was to determine whether the performance of texture analysis is dependent on image resolution.
High-resolution (0.5×0.5 mm2 in-plane) coronal T2-weighted MRI of the brain were acquired from 12 patients with ALS and 19 healthy controls on a 4.7 Tesla MRI system. Image data sets at lower resolutions were created by down-sampling to 1×1, 2×2, 3×3, and 4×4 mm2. Texture features were extracted from a slice encompassing the corticospinal tract at the different resolutions and tested for their discriminatory power and correlations with clinical measures. Subjects were also classified by visual assessment by expert reviewers.
Texture features were different between ALS patients and healthy controls at 1×1, 2×2, and 3×3 mm2 resolutions. Texture features correlated with measures of upper motor neuron function and disability. Optimal classification performance was achieved when best-performing texture features were combined with visual assessment at 2×2 mm2 resolution (0.851 area under the curve, 83% sensitivity, 79% specificity).
Texture analysis can detect subtle abnormalities in MRI of ALS patients. The clinical yield of the method is dependent on image resolution. Texture analysis holds promise as a potential source of neuroimaging biomarkers in ALS.
Strategies for the involvement of primary care in the management of patients with presumed or diagnosed dementia are heterogeneous across Europe. We wanted to explore attitudes of primary care physicians (PCPs) when managing dementia: (i) the most popular cognitive tests, (ii) who had the right to initiate or continue cholinesterase inhibitor or memantine treatment, and (iii) the relationship between the permissiveness of these rules/guidelines and PCP's approach in the dementia investigations and assessment.
Key informant survey. Setting: Primary care practices across 25 European countries. Subjects: Four hundred forty-five PCPs responded to a self-administered questionnaire. Two-step cluster analysis was performed using characteristics of the informants and the responses to the survey. Main outcome measures: Two by two contingency tables with odds ratios and 95% confidence intervals were used to assess the association between categorical variables. A multinomial logistic regression model was used to assess the association of multiple variables (age class, gender, and perceived prescription rules) with the PCPs’ attitude of “trying to establish a diagnosis of dementia on their own.”
Discrepancies between rules/guidelines and attitudes to dementia management was found in many countries. There was a strong association between the authorization to prescribe dementia drugs and pursuing dementia diagnostic work-up (odds ratio, 3.45; 95% CI 2.28–5.23).
Differing regulations about who does what in dementia management seemed to affect PCP's engagement in dementia investigations and assessment. PCPs who were allowed to prescribe dementia drugs also claimed higher engagement in dementia work-up than PCPs who were not allowed to prescribe.
Simulation of turbulent flows with shocks employing subgrid-scale (SGS) filtering may encounter a loss of accuracy in the vicinity of a shock. This paper addresses the accuracy improvement of LES of turbulent flows in two ways: (a) from the SGS model standpoint and (b) from the numerical method improvement standpoint. In an internal report, Kotov et al. ( “High Order Numerical Methods for large eddy simulation (LES) of Turbulent Flows with Shocks”, CTR Tech Brief, Oct. 2014, Stanford University), we performed a preliminary comparative study of different approaches to reduce the loss of accuracy within the framework of the dynamic Germano SGS model. The high order low dissipative method of Yee & Sjögreen (2009) using local flow sensors to control the amount of numerical dissipation where needed is used for the LES simulation. The considered improved dynamics model approaches include applying the one-sided SGS test filter of Sagaut & Germano (2005) and/or disabling the SGS terms at the shock location. For Mach 1.5 and 3 canonical shock-turbulence interaction problems, both of these approaches show a similar accuracy improvement to that of the full use of the SGS terms. The present study focuses on a five levels of grid refinement study to obtain the reference direct numerical simulation (DNS) solution for additional LES SGS comparison and approaches. One of the numerical accuracy improvements included here applies Harten's subcell resolution procedure to locate and sharpen the shock, and uses a one-sided test filter at the grid points adjacent to the exact shock location.
Therapeutic application of the physiologic process of fibrinolysis (thrombolysis) was first attempted in the late 1950s in individuals with various thrombotic lesions, comprising peripheral venous, arterial, central nervous system (CNS) and coronary involvement . Over time and after rigorous clinical study, intravascular thrombolysis has come to occupy a critical role in the management of thrombotic disease in adults, with clear, approved indications for acute myocardial infarction, stroke and massive pulmonary embolism (PE). Its utility has also been investigated recently via controlled clinical trials in adults with occlusive lower extremity deep vein thrombosis (DVT), with promising results ; current guidelines also suggest its use in selected patients with this common condition .
For many reasons, however, including the lower incidence of thrombotic disease, consequent difficulty in completing high-quality clinical trials and heightened concerns for bleeding risks in young infants and children, the indications, dosing regimens and safety profiles for thrombolysis in pediatric patients are not as well established. Overall, the quality of evidence supporting the clinical management of pediatric patients via thrombolysis remains low given that a large proportion of the existing literature consists of individual case reports and small case series. Most series have reported on clinically heterogeneous groups of patients, with varied sites of vascular involvement using a variety of thrombolytic dosing regimens and modalities. Several comprehensive literature reviews have been published compiling available safety, efficacy and dosing data from several hundred infants and children [4–6]. Other recent review articles [7–9] summarize experience, expert opinion and important clinical management principles, while practice guidelines [10,11] are available to provide formal recommendations based on existing evidence.
We present the first measurement of the evolution of the apparent projected shape of galaxy clusters from 0.2≲ z≲2. We measure the ellipticities (εcl) of homogeneously selected galaxy clusters over this wide redshift range. We confirm the predictions of N-body simulations that clusters are more elongated at higher redshift, finding the mean projected ellipticity changes linearly from 0.36±0.01 to 0.25±0.01 over that range. The fraction of relaxed clusters (defined as having εcl<0.2) is 9+5-3% at z∼1.8, steadily increasing to 42+7-6% by z∼0.3. Because more spherical clusters have a higher degree of virialization, our result shows significant evolution in the degree of cluster virialization over cosmic time.
A study of 7,388 consecutive patients after hepatic resection between 2011 and 2012 identified hepatolithiasis, cirrhosis, and intraoperative blood transfusion as the only independent risk factors of both incisional and organ/space surgical site infection (SSI). Patients with these conditions should be cared for with caution to lower SSI rates.
Thin-film absorber layers for photovoltaics have attracted much attention for their potential for low cost per unit power generation, due both to reduced material consumption and to higher tolerance for defects such as grain boundaries. Cu2ZnGeSe4 (CZGSe) comprises one such material system which has a near-optimal direct band gap of 1.6 eV for absorption of the solar spectrum, and is made primarily from earth-abundant elements.
CZGSe metallic precursor films were sputtered from Cu, Zn, and Ge onto Mo-coated soda lime glass substrates. These were then selenized in a two-zone close-space sublimation furnace using elemental Se as the source, with temperatures in the range of 400 to 500 C, and at a variety of background pressures. Films approximately 1-1.5 µm thick were obtained with the expected stannite crystal structure.
Next, Cu2ZnSnSe4 (CZTSe), which has a direct band gap of 1.0 eV, was prepared in a similar manner and combined with CZGSe as either compositionally homogeneous or layered absorbers. The compositional uniformity of selenide absorbers made by selenizing compositionally homogeneous Cu-Zn-Ge-Sn precursor layers was determined and the band gap as a function of composition was investigated in order to demonstrate that the band gap is tuneable for a range of compositions. For layered Cu-Zn-Ge/Cu-Zn-Sn precursor films, the composition profile was measured before and after selenization to assess the stability of the layered structure, and its applicability for forming a band-gap-graded device for improved current collection.
In July 2011, a cluster of Yersinia enterocolitica infections was detected in southwestern Pennsylvania, USA. We investigated the outbreak's source and scope in order to prevent further transmission. Twenty-two persons were diagnosed with yersiniosis; 16 of whom reported consuming pasteurized dairy products from dairy A. Pasteurized milk and food samples were collected from this dairy. Y. enterocolitica was isolated from two products. Isolates from both food samples and available clinical isolates from nine dairy A consumers were indistinguishable by pulsed-field gel electrophoresis. Environmental and microbiological investigations were performed at dairy A and pasteurization deficiencies were noted. Because consumption of pasteurized milk is common and outbreaks have the potential to become large, public health interventions such as consumer advisories or closure of the dairy must be implemented quickly to prevent additional cases if epidemiological or laboratory evidence implicates pasteurized milk as the outbreak source.
The variable high-order multiblock overlapping (overset) grids method of Sjögreen & Yee [CiCP, Vol. 5, 2009] for a perfect gas has been extended to nonequilibrium flows. This work makes use of the recently developed high-order well-balanced shock-capturing schemes and their filter counterparts [Wang et al., J. Comput. Phys., 2009, 2010] that exactly preserve certain non-trivial steady state solutions of the chemical nonequilibrium governing equations. Multiscale turbulence with strong shocks and flows containing both steady and unsteady components is best treated by mixing of numerical methods and switching on the appropriate scheme in the appropriate subdomains of the flow fields, even under the multiblock grid or adaptive grid refinement framework. While low dissipative sixth- or higher-order shock-capturing filter methods are appropriate for unsteady turbulence with shocklets, second- and third- order shock-capturing methods are more effective for strong steady or nearly steady shocks in terms of convergence. It is anticipated that our variable high-order overset grid framework capability with its highly modular design will allow for an optimum synthesis of these new algorithms in such a way that the most appropriate spatial discretizations can be tailored for each particular region of the flow. In this paper some of the latest developments in single block high-order filter schemes for chemical nonequilibrium flows are applied to overset grid geometries. The numerical approach is validated on a number of test cases characterized by hypersonic conditions with strong shocks, including the reentry flow surrounding a 3D Apollo-like NASA Crew Exploration Vehicle that might contain mixed steady and unsteady components, depending on the flow conditions.
Recently, novel dietary oils with modified fatty acid profiles have been manufactured to improve fatty acid intakes and reduce CVD risk. Our objective was to evaluate the efficacy of novel high-oleic rapeseed (canola) oil (HOCO), alone or blended with flaxseed oil (FXCO), on circulating lipids and inflammatory biomarkers v. a typical Western diet (WD). Using a randomised, controlled, crossover trial, thirty-six hypercholesterolaemic subjects consumed three isoenergetic diets for 28 d each containing approximately 36 % energy from fat, of which 70 % was provided by HOCO, FXCO or WD. Dietary fat content of SFA, MUFA, PUFA n-6 and n-3 was 6, 23, 5, 1 % energy for HOCO; 6, 16, 5, 7·5 % energy for FXCO; 11·5, 16, 6, 0·5 % energy for WD. After 28 d, compared with WD, LDL-cholesterol was reduced 15·1 % (P < 0·001) with FXCO and 7·4 % (P < 0·001) with HOCO. Total cholesterol (TC) was reduced 11 % (P < 0·001) with FXCO and 3·5 % (P = 0·002) with HOCO compared with WD. Endpoint TC differed between FXCO and HOCO (P < 0·05). FXCO consumption reduced HDL-cholesterol by 8·5 % (P < 0·001) and LDL:HDL ratio by 7·5 % (P = 0·008) v. WD. FXCO significantly decreased E-selectin concentration compared with WD (P = 0·02). No differences were observed in inflammatory markers after the consumption of HOCO compared with WD. In conclusion, consumption of novel HOCO alone or when blended with flaxseed oil is cardioprotective through lipid-lowering effects. The incorporation of flaxseed oil may also target inflammation by reducing plasma E-selectin.
This study aimed (1) to investigate the relationship between the presence of lymph node central necrosis, viewed on pre-operative computed tomography imaging, and the occurrence of histopathologically determined metastatic lymph node extracapsular spread and (2) to determine whether a larger scale study would be valuable.
Materials and methods:
Pre-operative computed tomography scans, surgical records and post-operative histopathological analysis results were reviewed for 19 consecutive neck dissections performed in 17 patients with head and neck squamous cell carcinoma.
A total of 20/26 (77 per cent) lymph nodes with central necrosis had extracapsular spread on histopathological analysis. Twenty of 21 (95 per cent) lymph nodes with extracapsular spread had central necrosis on pre-operative computed tomography. Thirty-four of 40 (85 per cent) lymph nodes without extracapsular spread had no evidence of central necrosis on computed tomography. Only three of 12 (25 per cent) patients with lymph node central necrosis identified on pre-operative computed tomography were found to have actual necrosis on final histopathological analysis.
Lymph node central necrosis viewed on pre-operative computed tomography scans is a useful indicator of metastatic lymph node extracapsular spread, with a sensitivity of 95 per cent, a specificity of 85 per cent, a positive predictive value of 69 per cent and a negative predictive value of 98 per cent. Lymph node diameter is not a sensitive indicator of extracapsular spread.
We use deep nIR imaging of 15 galaxy clusters at z ≃ 1 to study the build-up of the red-sequence in rich clusters since the Universe was half its present age. We measured, for the first time, the luminous-to-faint ratio of red-sequence galaxies at z=1 from a large ensemble of clusters, and found an increase of 100% in the ratio of luminous-to-faint red-sequence galaxies from z=0.45 to 1.0. The measured change in this ratio as function of redshift is well-reproduced by a simple evolutionary model developed in this work, that consists in an early truncation of the star formation for bright cluster galaxies and a delayed truncation for faint cluster galaxies.