To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Cognitive impairment is strongly linked with persistent disability in people with mood disorders, but the factors that explain cognitive impairment in this population are unclear.
To estimate the total effect of (a) bipolar disorder and (b) major depression on cognitive function, and the magnitude of the effect that is explained by potentially modifiable intermediate factors.
Cross-sectional study using baseline data from the UK Biobank cohort. Participants were categorised as having bipolar disorder (n = 2709), major depression (n = 50 975) or no mood disorder (n = 102 931 and n = 105 284). The outcomes were computerised tests of reasoning, reaction time and memory. The potential mediators were cardiometabolic disease and psychotropic medication. Analyses were informed by graphical methods and controlled for confounding using regression, propensity score-based methods and G-computation.
Group differences of small magnitude were found on a visuospatial memory test. Z-score differences for the bipolar disorder group were in the range −0.23 to −0.17 (95% CI −0.39 to −0.03) across different estimation methods, and for the major depression group they were approximately −0.07 (95% CI −0.10 to −0.03). One-quarter of the effect was mediated via psychotropic medication in the bipolar disorder group (−0.05; 95% CI −0.09 to −0.01). No evidence was found for mediation via cardiometabolic disease.
In a large community-based sample in middle to early old age, bipolar disorder and depression were associated with lower visuospatial memory performance, in part potentially due to psychotropic medication use. Mood disorders and their treatments will have increasing importance for population cognitive health as the proportion of older adults continues to grow.
Declaration of interest
I.J.D. is a UK Biobank participant. J.P.P. is a member of the UK Biobank Steering Committee.
The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams.
The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here.
The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020.
Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.
To describe the functions of the Aneurin Bevan University Health Board Risk Reference Panel and characterise the typical referrals presented and outcomes from the panel. A structured thematic analysis was performed on verbatim transcripts of 48 panel sessions.
The 79 codes identified were grouped into 16 subthemes. Four principal themes were identified: two characterising cases brought to the panel (childhood risk factors and current presenting difficulties) and two describing advice given (risk management and wider organisational issues). Quotations are given to illustrate cases presented and advice given by the panel.
The panel provides a valuable source of special expertise in the management of complex and exceptional cases where risk of harm is significant and clinical teams have ongoing concerns. This paper describes a model of peer-working to support staff and may further reduce the risk of harm associated with mental illness.
Geochemical and related studies have been made of near-surface sediments from the River Clyde estuary and adjoining areas, extending from Glasgow to the N, and W as far as the Holy Loch on the W coast of Scotland, UK. Multibeam echosounder, sidescan sonar and shallow seismic data, taken with core information, indicate that a shallow layer of modern sediment, often less than a metre thick, rests on earlier glacial and post-glacial sediments. The offshore Quaternary history can be aligned with onshore sequences, with the recognition of buried drumlins, settlement of muds from quieter water, probably behind an ice dam, and later tidal delta deposits. The geochemistry of contaminants within the cores also indicates shallow contaminated sediments, often resting on pristine pre-industrial deposits at depths less than 1m. The distribution of different contaminants with depth in the sediment, such as Pb (and Pb isotopes), organics and radionuclides, allow chronologies of contamination from different sources to be suggested. Dating was also attempted using microfossils, radiocarbon and 210Pb, but with limited success. Some of the spatial distribution of contaminants in the surface sediments can be related to grain-size variations. Contaminants are highest, both in absolute terms and in enrichment relative to the natural background, in the urban and inner estuary and in the Holy Loch, reflecting the concentration of industrial activity.
Important Bird and Biodiversity Areas (IBAs) are sites identified as being globally important for the conservation of bird populations on the basis of an internationally agreed set of criteria. We present the first review of the development and spread of the IBA concept since it was launched by BirdLife International (then ICBP) in 1979 and examine some of the characteristics of the resulting inventory. Over 13,000 global and regional IBAs have so far been identified and documented in terrestrial, freshwater and marine ecosystems in almost all of the world’s countries and territories, making this the largest global network of sites of significance for biodiversity. IBAs have been identified using standardised, data-driven criteria that have been developed and applied at global and regional levels. These criteria capture multiple dimensions of a site’s significance for avian biodiversity and relate to populations of globally threatened species (68.6% of the 10,746 IBAs that meet global criteria), restricted-range species (25.4%), biome-restricted species (27.5%) and congregatory species (50.3%); many global IBAs (52.7%) trigger two or more of these criteria. IBAs range in size from < 1 km2 to over 300,000 km2 and have an approximately log-normal size distribution (median = 125.0 km2, mean = 1,202.6 km2). They cover approximately 6.7% of the terrestrial, 1.6% of the marine and 3.1% of the total surface area of the Earth. The launch in 2016 of the KBA Global Standard, which aims to identify, document and conserve sites that contribute to the global persistence of wider biodiversity, and whose criteria for site identification build on those developed for IBAs, is a logical evolution of the IBA concept. The role of IBAs in conservation planning, policy and practice is reviewed elsewhere. Future technical priorities for the IBA initiative include completion of the global inventory, particularly in the marine environment, keeping the dataset up to date, and improving the systematic monitoring of these sites.
A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.
Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).
All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.
Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.
New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.
We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.
We included outcomes for 230,099 registered patients, assigned to ranked risk groups.
Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.
Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.
Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.
Adequate pain relief at the scene of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilize and long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia Iliaca Compartment Block (FICB) is a procedure routinely undertaken by clinicians in emergency departments for hip fracture patients, but use by paramedics at the scene of emergency calls, is not yet evaluated (1).
We undertook a randomized controlled feasibility trial using novel audited scratchcard randomization to allocate eligible patients to FICB or usual care. Paramedics are recruited and trained to assess patients for hip fracture and carry out FICB. We will follow up patients to assess accuracy of paramedic diagnosis, acceptability to patients and paramedics, compliance of paramedics and also measures of pain, side effects, time in hospital and quality of life in order to plan a full trial if appropriate. The primary outcome measure is health related quality of life, measured using Short Form (SF)-12 at 1 and 6 months. Interviews and focus groups will be used to understand acceptability of FICB to patients and paramedics. This study was funded by Health and Care Research Wales (1003).
We have developed:
•paramedic pathway to assess patients for hip fracture and FICB
•paramedic training package, delivered by Consultant Anaesthetist
To date we have recruited nineteen paramedics; ten are fully trained and recruiting patients, the remainder are being trained. Fifty-four patients have been randomized and thirty-five have consented to follow-up. Thirteen 1-month and five 6-month follow-up questionnaires have been received.
This study will enable us to recommend whether to undertake a definitive multi-centre randomized controlled trial of FICB by paramedics for hip fracture to determine if the procedure is effective for patients and worthwhile for the National Health Service.
Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.
We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.
We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.
Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.
Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.
The lowest glacial cirques in Wales are in the South Wales Coalfield and in western mid-Wales: the highest are in the northeast and on the highest mountains. Floor altitudes show great local variability, but in general rise to the northeast in most of Wales and northward in southern Wales, as does the former glaciation level (from 470–710 m a.s.l.). The pattern is similar for reconstructed Younger Dryas glaciers, which occupied the higher and even some of the lower cirques. If cirque development had spread to lower areas as the ice sheet built up, cirques would be expected in peripheral areas such as the northeast and southwest, away from the main ice-sheet sources. This is not seen and there is no clear evidence of time-transgressive cirque glaciation. Cirques relate to phases of glaciation with an ELA a little below that in the Younger Dryas.
Although World Glacier Inventory (WGI) data for 241 local glaciers (>1 km2 in area) in Svalbard show a mean aspect of 014˚ ± 24˚, their mid-altitudes are lowest for an aspect of 109˚ ± 46˚, which is inconsistent. Further data are generated here for the altitude, length and source aspect of 205 local glaciers (0.3–6.0 km long) in the main area of local glaciation in Svalbard, Nordenskiöld Land. All four mountain blocks have mean glacier source aspects of 356˚ to 018˚; the overall mean is 011˚ ± 8˚. Mid-altitudes are lowest at 042˚ ±21˚, predicted to be 53 m lower than on opposite aspects. Lowest altitudes are predicted at 009˚ to 030˚, averaging 157 m lower than on opposite aspects. These results show that local, land-terminating glaciers around 78˚ N are affected more by north-south radiation receipt contrasts than by wind effects, consistent with the trend found across most other Arctic regions. It is concluded that, although weaker than in mid-latitudes, contrasts due to slope climates are substantial even in Arctic glaciers. This is apparent only when small, steep glaciers are inventoried: WGI data are incomplete and users need to check the thresholds of coverage.
North–south and east–west differences in firn-line altitude, equilibrium-line altitude or middle altitudes of glaciers can be separated by regression on the cosine and sine of glacier aspect (accumulation area azimuth). Allowing for regional trends in altitude, the north–south differences expected from radiation and shade effects can be reliably quantified from World Glacier Inventory (WGI) data. The north–south differences are greater in sunnier climates, mid-latitudes and steeper relief. Local altitude differences between north- and south-facing glaciers are commonly 70–320 m. Such asymmetry is near-universal, although weak in the Arctic and tropics. East–west contrasts are less, and found mainly in the tropics and areas most exposed to strong winds. Altitude, latitude, glacier gradient and height range, calculable from most of the WGI data, are potential controls on the degree of north–south contrast, as well as surrogates for climatic controls (temperature, precipitation, radiation and cloudiness). An asymmetric sine–cosine power model is developed to describe the variation of north–south contrast with latitude. Multiple regression over 51 regions shows altitude and latitude to be the strongest controls of this contrast. Aspect–altitude analysis for former glaciers provides new evidence of cloudiness.
We present a comprehensive new inventory of surge-type glaciers on the Novaya Zemlya archipelago, using high-resolution (up to 4 m) satellite imagery from 1976/77 (Hexagon), 1989 (Landsat TM), 2001 (Landsat ETM+) and 2006 (ASTER). A total of 692 glaciers and their forelands were observed for glaciological and geomorphological criteria indicative of glacier surging (e.g. looped moraines, heavy surface crevassing, surface potholes, thrust-block moraines, concertina eskers). This enabled the identification of 32 potential surge-type glaciers (compared with four previously identified) representing 4.6% of the total but 18% by glacier area. We assess the characteristics of surge-type glaciers. Surge-type glaciers are statistically different from non-surge-type glaciers in terms of their area, length, surface slope, minimum elevation, mid-range elevation and terminus type. They are typically long (median length 18.5 km), large (median area 106.8 km2) outlet glaciers, with relatively low overall surface slopes (median slope 1.7°) and tend to terminate in water (marine or lacustrine). They are predominantly directed towards and located in the more maritime western region of the Russian Arctic, and we suggest that surge occurrence might be related to large and complex catchment areas that receive increased delivery of precipitation from the Barents Sea.
In the relatively gas-rich, pure exponential disk galaxies, available data is accumulating which suggests that the distribution of starformation in the disk either shows no radial variation, or else has a scale-length which is much longer than that of the stars.
Two observational programs which provide new information about particular LBVs through investigations of their immediate surroundings are described. (1) Digital spectral classification of OB supergiants in compact groups apparently associated with Radcliffe 127 and S Doradus has revealed several interesting objects and indicates which of them are likely to be generically related to the LBVs. (2) Velocity-resolved images of the Eta Carinae shell show qualitatively new features, which will contribute substantially to the interpretation of its complex spatial/kinematical structure.
Like many mountain ranges, the Coast Mountains of British Columbia, Canada, have undergone both local and ice-sheet glaciation. Effects of ice sheets are concentrated along major valleys and on adjacent spurs and passes which carried strong flows of diffluent ice. The major valleys are broad glacial troughs with frequent rock basins. Their slopes are broken into rounded, steep-sided bosses whalebacks abraded on all sides: they are of the order of 100 m to 1 km long, and 10 m high. In the southern Coast Mountains, the distribution of these whalebacks is consistent with a proposed pattern of former ice streams 1.0–2.1 km thick, within the Cordilleran ice sheet. They are best developed where geological structures parallel the valley and thus the former ice-flow direction, but they are found on a range of lithologies and some are transverse to structure. The whalebacks provide an impression of glacial streamlining, and occasionally grade into rock drumlins. Roches moutonnées are rare in the major troughs.
It is hypothesised that these whalebacks and rock drumlins develop under ice streams of Greenland or East Antarctic type, sliding rapidly over bedrock and exploiting rock weaknesses to produce streamlined features. Lee slopes are abraded when thick ice suppresses bed separation, even with rapid flow; basal ice of low viscosity would aid this suppression. Water pressures under the ice streams may have remained high, so that lee-side plucking was rare; such plucking is most likely where pressure fluctuates dramatically, and especially when lee cavities under active ice reach atmospheric pressure.
Over a distance of 150 km inland across British Columbia, glaciation level (altitudinal threshold for glacier generation) rises north-eastward from 1800 m near Jervis Inlet, to 2800m near Lillooet on Fraser River. The methods of Østrem (1966b) are revised for more detailed work from air photographs; inclusion of small but active glaciers gives a glaciation level some 200 m below Østrem’s from 1:250 000 maps, or 110 m below that from 1:50 000 maps.
Mountains which rise slightly above the altitudinal threshold invariably support glaciers only on their northerly slopes. Mountain crests need to be some 300 m higher before they support glaciers on most slopes: this defines an “all-sided” glaciation level. Since summit heights vary from 2500 to 2900 m through most of the transect considered here, east- and west-facing glacier sources are found mainly in the coastal half; south-facing sources are rare outside icefields.
For particular mountain ranges bounded by valleys and low passes, the aspects (azimuths) of glacier sources can be summarised by vector analysis. The higher the range rises above glaciation level, the more widespread the aspects represented and the weaker the resultant vector strength. Strengths as high as 90% are observed on landward ranges with a relatively sunny, continental climate, while 20-60% is found for coastal ranges where cloudiness reduces slope variations in incident solar radiation. Vector mean aspects throughout are close to north.
Perennial lee drifts on icefields show that wind directions during and immediately after snowfalls are from the south or from south-south-west. Together with orographic details of the glaciation level, this suggests that snow-bearing winds come from the south rather than the west. These winds reinforce radiation contrasts, giving north-south asymmetry of glacier aspect even near the coast.
Supraglacial ponds play a key role in absorbing atmospheric energy and directing it to the ice of debris-covered glaciers, but the spatial and temporal distribution of these features is not well documented. We analyse 172 Landsat TM/ETM+ scenes for the period 1999–2013 to identify thawed supraglacial ponds for the debris-covered tongues of five glaciers in the Langtang Valley of Nepal. We apply an advanced atmospheric correction routine (Landcor/6S) and use band ratio and image morphological techniques to identify ponds and validate our results with 2.5 m Cartosat-1 observations. We then characterize the spatial, seasonal and interannual patterns of ponds. We find high variability in pond incidence between glaciers (May–October means of 0.08–1.69% of debris area), with ponds most frequent in zones of low surface gradient and velocity. The ponds show pronounced seasonality, appearing in the pre-monsoon as snow melts, peaking at the monsoon onset at 2% of debris-covered area, then declining in the post-monsoon as ponds drain or freeze. Ponds are highly recurrent and persistent, with 40.5% of pond locations occurring for multiple years. Rather than a trend in pond cover over the study period, we find high interannual variability for each glacier after controlling for seasonality.
Photoionization and shock models of the extended emissionline regions (EELRs) in active galaxies demonstrate that the optical emission lines alone are a poor discriminant of the excitation mechanism. Combining optical and UV data provides a discriminant between nuclear photoionization and autoionizing shock models. Hubble Space Telescope UV spectrophotometry of two Seyferts suggests that the EELRs in these objects are probably photoionized by the nucleus.
The relative contribution of demographic, lifestyle and medication factors to the association between affective disorders and cardiometabolic diseases is poorly understood.
To assess the relationship between cardiometabolic disease and features of depresion and bipolar disorder within a large population sample.
Cross-sectional study of 145 991 UK Biobank participants: multivariate analyses of associations between features of depression or bipolar disorder and five cardiometabolic outcomes, adjusting for confounding factors.
There were significant associations between mood disorder features and ‘any cardiovascular disease’ (depression odds ratio (OR) = 1.15, 95% CI 1.12–1.19; bipolar OR = 1.28, 95% CI 1.14–1.43) and with hypertension (depression OR = 1.15, 95% CI 1.13–1.18; bipolar OR = 1.26, 95% CI 1.12–1.42). Individuals with features of mood disorder taking psychotropic medication were significantly more likely than controls not on psychotropics to report myocardial infarction (depression OR = 1.47, 95% CI 1.24–1.73; bipolar OR = 2.23, 95% CI 1.53–3.57) and stroke (depression OR = 2.46, 95% CI 2.10–2.80; bipolar OR = 2.31, 95% CI 1.39–3.85).
Associations between features of depression or bipolar disorder and cardiovascular disease outcomes were statistically independent of demographic, lifestyle and medication confounders. Psychotropic medication may also be a risk factor for cardiometabolic disease in individuals without a clear history of mood disorder.