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Clinical diagnostics in sudden onset disasters have historically been limited. We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type 2 emergency medical team (EMT) field hospital.
Available diagnostic platforms were reviewed and selected against in field need. Platforms included HemoCue301/WBC DIFF, i-STAT, BIOFIRE FILMARRAY multiplex rt-PCR, Olympus BX53 microscopy, ABO/Rh grouping, and specific rapid diagnostic tests. This equipment was trialed in Katherine, Australia, and Dili, Timor-Leste.
During the initial deployment, an evaluation of FilmArray tests was successful using blood culture identification, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) hemoglobin values were compared on Sysmex XN 550 (r = 0.94). HemoCue WBC DIFF had some variation, dependent on the cell, when compared with Sysmex XN 550 (r = 0.88-0.16). i-STAT showed nonsignificant differences against Vitros 250. Further evaluation of FilmArray in Dili, Timor-Leste, diagnosed 117 pathogens on 168 FilmArray pouches, including 25 separate organisms on blood culture and 4 separate cerebrospinal fluid pathogens.
This mobile laboratory represents a major advance in sudden onset disaster. Setup of the service was quick (< 24 hr) and transport to site rapid. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostic capability.
We designed, developed, and implemented a new hospital-based health technology assessment (HB-HTA) program called Smart Innovation. Smart Innovation is a decision framework that reviews and makes technology adoption decisions. Smart Innovation was meant to replace the fragmented and complex process of procurement and adoption decisions at our institution. Because use of new medical technologies accounts for approximately 50 percent of the growth in healthcare spending, hospitals and integrated delivery systems are working to develop better processes and methods to sharpen their approach to adoption and management of high cost medical innovations.
The program has streamlined the decision-making process and added a robust evidence review for new medical technologies, aiming to balance efficiency with rigorous evidence standards. To promote system-wide adoption, the program engaged a broad representation of leaders, physicians, and administrators to gain support.
To date, Smart Innovation has conducted eleven HB-HTAs and made clinician-led adoption decisions that have resulted in over $5 million dollars in cost avoidance. These are comprised of five laboratory tests, three software-assisted systems, two surgical devices, and one capital purchase.
Smart Innovation has achieved cost savings, avoided uncertain or low-value technologies, and assisted in the implementation of new technologies that have strong evidence. The keys to its success have been the program's collaborative and efficient decision-making systems, partnerships with clinicians, executive support, and proactive role with vendors.
In lifecourse studies that encompass the adolescent period, the assessment of pubertal status is important, but can be challenging. We aimed to identify current methods for pubertal assessment and assess their appropriateness for population-based research by combining a review of the literature with the views of experts in the field. We searched bibliographic databases, extracted data and assessed study quality to inform a workshop with 21 experts. Acceptability of different approaches was explored with a panel of ten adolescents. We screened 11,935 abstracts, assessed 157 articles and summarised results from 38 articles. Combining these with the opinions of experts, self-assessment was found to be a practical method for use in studies where agreement with the gold standard of clinical assessment by physical examination to within one Tanner stage was acceptable. Serial measures of height and foot size accurately indicated timing of the pubertal growth spurt and age at peak height velocity, and were seen as feasible within longitudinal studies. Hormonal and radiological methods did not offer a practical means of assessing pubertal status. Assessment of voice maturation was promising, but needed validation. Young people thought that self-assessment, foot size and voice assessments were acceptable, and preferred an assessor of the same sex for clinical assessment. This review thus informs researchers working in lifecourse and adolescent health, and identifies future directions in order to improve validity of the methods.
The Beck’s Petrel Pseudobulweria beckii is a ‘Critically Endangered’ seabird whose breeding sites remain unknown. Historic observations suggest the species’ distribution is concentrated in the Bismarck Archipelago and particularly southern New Ireland. Over the course of two research expeditions in 2016 and 2017 we used on-land and at-sea observations, local interviews and satellite telemetry to understand the distribution of the species, its at-sea movements and potential breeding locations. Land-based and at-sea observations indicated that the area of Silur Bay in southern New Ireland was a significant site for Beck’s Petrel with numbers of birds increasing near shore prior to dusk and birds observed in spotlights over land. A local population is estimated to be in the low thousands. In 2017 a single Beck’s was captured at sea, fitted with a satellite transmitter and tracked for eight months. This bird maintained a core distribution off the south-east coast of New Ireland and north of Bougainville for 122 days. During the tracking period, the bird was located over land at night seven times; predominantly over southern New Ireland, where the signal was also lost for extended periods suggesting occupancy of an underground burrow. In August the bird migrated 1,400 km to a core pelagic habitat north of West Papua before the signal was eventually lost. Our combination of land- and sea-based observations and analysis of behaviour from satellite tracking supports the conclusion that a breeding site for Beck’s Petrel lies in the inland mountains of southern New Ireland and most likely in the high-altitude zone (> 2000 m) of the Hans Meyer Range. Further investigations are required to determine the exact location of breeding colonies in the mountains of southern New Ireland and the importance of a potential west Papuan non-breeding pelagic habitat for the species.
The spatial-intensity profile of light reflected during the interaction of an intense laser pulse with a microstructured target is investigated experimentally and the potential to apply this as a diagnostic of the interaction physics is explored numerically. Diffraction and speckle patterns are measured in the specularly reflected light in the cases of targets with regular groove and needle-like structures, respectively, highlighting the potential to use this as a diagnostic of the evolving plasma surface. It is shown, via ray-tracing and numerical modelling, that for a laser focal spot diameter smaller than the periodicity of the target structure, the reflected light patterns can potentially be used to diagnose the degree of plasma expansion, and by extension the local plasma temperature, at the focus of the intense laser light. The reflected patterns could also be used to diagnose the size of the laser focal spot during a high-intensity interaction when using a regular structure with known spacing.
Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection.
We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure.
During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment.
When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
The optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre’s experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.
Materials and methods
Between 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated.
Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.
Single-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.
The cat flea, Ctenocephalides felis, is a major pest species on companion animals thus of significant importance to the animal health industry. The aim of this study was to develop sampling and storage protocols and identify stable reference genes for gene expression studies to fully utilize the growing body of molecular knowledge of C. felis. RNA integrity was assessed in adult and larvae samples, which were either pierced or not pierced and stored in RNAlater at ambient temperature. RNA quality was maintained best in pierced samples, with negligible degradation evident after 10 days. RNA quality from non-pierced samples was poor within 3 days. Ten candidate reference genes were evaluated for their stability across four group comparisons (developmental stages, genders, feeding statuses and insecticide-treatment statuses). Glyceraldehyde 3 phosphate dehydrogenase (GAPDH), 60S ribosomal protein L19 (RPL19) and elongation factor-1α (Ef) were ranked highly in all stability comparisons, thus are recommended as reference genes under similar conditions. Employing just two of these three stable reference genes was sufficient for accurate normalization. Our results make a significant contribution to the future of gene expression studies in C. felis, describing validated sample preparation procedures and reference genes for use in this common pest.
Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a ‘teachable moment’ for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.
Various environmental factors have been associated with the timing of eruption of primary dentition, but the evidence to date comes from small studies with limited information on potential risk factors. We aimed to investigate associations between tooth emergence patterns and pre-conception, pregnancy and postnatal influences. Dentition patterns were recorded at ages 1 and 2 years in 2915 children born to women in the Southampton Women’s Survey from whom information had been collected on maternal factors before conception and during pregnancy. In mutually adjusted regression models we found that: children were more dentally advanced at ages 1 and 2 years if their mothers had smoked during pregnancy or they were longer at birth; mothers of children whose dental development was advanced at age 2 years tended to have poorer socioeconomic circumstances, and to have reported a slower walking speed pre-pregnancy; and children of mothers of Asian ethnicity had later tooth development than those of white mothers. The findings add to the evidence of environmental impacts on the timing of the eruption of primary dentition in indicating that maternal smoking during pregnancy, socio-economic status and physical activity (assessed by reported walking speed) may influence the child’s primary dentition. Early life factors, including size at birth are also associated with dentition patterns, as is maternal ethnicity.
Because of its central role in the global carbon cycle, quantifying the biomass of photosynthetic microalgae in the oceans is crucial to our ability to estimate the oceans’ carbon drawdown. Many traditional methods of primary production assessment have proven to be extremely time consuming and, consequently, have handled only very small sample sizes. The recent advent of in situ bio-optical sensors, such as the water quality monitor (WQM), is now providing lower cost and higher throughput data on these crucial biological communities. These WQMs, however, only quantify the total fluorescence of all individual cells within their optical sample windows, irrespective of size. In this paper, we further develop an established model, based on Pareto random variables, of the size structure of the microalgae community to understand the effect of the WQMs’ sampling and data pooling on their estimates of algal biomass. Unfortunately, evaluating sums of Pareto variables is a notoriously difficult problem. Here, we utilize an approximation for the right-tail of the resulting distribution to derive parameter estimates for the underlying size structure of the microalgae community.
Methiozolin is a new herbicide from South Korea currently under development in the United States for PRE and POST annual bluegrass control in bentgrass and most other cool- and warm-season turfgrasses. Greenhouse studies were conducted in 2012 at the University of California, Riverside, CA, and Auburn University, Auburn, AL, to evaluate the relative tolerance of three bentgrass species comprised of nine creeping bentgrass (CRBG) cultivars, velvet bentgrass (VBG) and colonial bentgrass (COBG) to methiozolin at 0, 0.6, 1.1, 2.2, 4.5 and 9.0 kg ai ha−1. Methiozolin was applied 7 wk after seeding, followed by a second application 5 wk later. Methiozolin rates that produced 25% injury (TI25) and 50% clipping dry weight reduction (GR50) relative to a nontreated control for each species or cultivar were calculated using four-parameter logistic regression. Turf injury rates at 21 d after second treatment (DAT2) were the most consistent in describing relative tolerance among bentgrass species. Overall, CRBG was more tolerant to methiozolin than VBG or COBG. After two applications, methiozolin rates that caused TI25 were 1.1, 0.2, and 0.3 kg ha−1 for CRBG (across all cultivars), VBG, and COBG, respectively. VBG and COBG were not tolerant of sequential methiozolin applications at rates necessary to control annual bluegrass under field conditions. Herbicide rates that caused TI25 and GR50 decreased with the second application. ‘Penn A-4’ CRBG exhibited the highest TI25 28 d after initial treatment (DAIT) at University of California at Riverside (4.5 kg ha−1), but only 2.5 kg ha−1 with two applications by 21 DAT2. All CRBG cultivars tested tolerated methiozolin at 0.5 kg ha−1, the recommended sequential use rate for putting greens in Korea.
The salience of major powers and the status they are attributed in international politics have been of central concern to both scholars and practitioners. The focus on major powers is at least as old as Thucydides, who noted in the Melian debate the unique advantages these states possessed in structuring relations between states. More recently, realists, neorealists, long-cycle theorists, hierarchical theorists, power transition theorists, and liberal institutionalists have all focused on major powers as critical to ordering interstate relations, as well as attempts to change those orders.
One aspect of being a major power is the status one receives from the policy makers of other states. The attribution of status to major powers – separate from their capabilities – has stubbornly persisted in significance across empirical conflict models, appearing as a predictor of conflict initiation, alliance formation and membership, involvement in militarized interstate disputes (MIDs) and crises, and multilateralism. Such status attribution, as both international relations (IR) scholars and historians have long recognized, is not a mirror reflection of the capabilities of these powers. Italy and Austria-Hungary are two clear historical cases of states that continued to receive high status attribution long after they no longer had the capacity or the willingness to act as major powers.
We report on an influenza B outbreak in an Ontario long-term care facility in which 2 immunized residents receiving oseltamivir prophylaxis for at least 5 days developed laboratory-confirmed influenza B infection. All isolates were tested for the most common oseltamivir resistance, and none of them had resistance identified.
Annual bluegrass is a problematic weed in bermudagrass and other intensively maintained turfgrasses. Flumioxazin is reported to control annual bluegrass both PRE and POST; however, as a contact herbicide, flumioxazin injures actively growing bermudagrass. Research was conducted in Alabama and California to evaluate optimal flumioxazin application timing for annual bluegrass control, bermudagrass response, and overall sward quality in the field, and to assess annual bluegrass control at various growth stages in the greenhouse. November and December application timings resulted in the best balance of the three parameters. When bermudagrass was not dormant at application, treatment resulted in necrosis of green tissues and thus induced dormancy. The herbicide-induced dormancy resulted in better sward quality due to more uniform and therefore more aesthetically pleasing dormant turfgrass relative to natural dormancy. Flumioxazin at 0.43 kg ai ha−1 resulted in better annual bluegrass control and improved sward quality relative to 0.21 kg ha−1. Incomplete POST annual bluegrass control from later applications was attributed to larger weed size, limiting the effectiveness of this contact herbicide. Greenhouse data corroborated field results and indicated that flumioxazin at 0.43 kg ha−1 controlled ≥ 95% of annual bluegrass up to two tillers. Flumioxazin can be utilized for PRE and POST annual bluegrass control, but utilization of this herbicide is limited to dormant bermudagrass unless induced dormancy can be tolerated, and POST control is limited to annual bluegrass plants ≤ two tillers in size.