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Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.
Given the common view that pre-exercise nutrition/breakfast is important for performance, the present study investigated whether breakfast influences resistance exercise performance via a physiological or psychological effect. Twenty-two resistance-trained, breakfast-consuming men completed three experimental trials, consuming water-only (WAT), or semi-solid breakfasts containing 0 g/kg (PLA) or 1·5 g/kg (CHO) maltodextrin. PLA and CHO meals contained xanthan gum and low-energy flavouring (approximately 122 kJ), and subjects were told both ‘contained energy’. At 2 h post-meal, subjects completed four sets of back squat and bench press to failure at 90 % ten repetition maximum. Blood samples were taken pre-meal, 45 min and 105 min post-meal to measure serum/plasma glucose, insulin, ghrelin, glucagon-like peptide-1 and peptide tyrosine-tyrosine concentrations. Subjective hunger/fullness was also measured. Total back squat repetitions were greater in CHO (44 (sd 10) repetitions) and PLA (43 (sd 10) repetitions) than WAT (38 (sd 10) repetitions; P < 0·001). Total bench press repetitions were similar between trials (WAT 37 (sd 7) repetitions; CHO 39 (sd 7) repetitions; PLA 38 (sd 7) repetitions; P = 0·130). Performance was similar between CHO and PLA trials. Hunger was suppressed and fullness increased similarly in PLA and CHO, relative to WAT (P < 0·001). During CHO, plasma glucose was elevated at 45 min (P < 0·05), whilst serum insulin was elevated (P < 0·05) and plasma ghrelin suppressed at 45 and 105 min (P < 0·05). These results suggest that breakfast/pre-exercise nutrition enhances resistance exercise performance via a psychological effect, although a potential mediating role of hunger cannot be discounted.
Herbicides have been a primary means of managing undesirable brush on grazing lands across the southwestern United States for decades. Continued encroachment of honey mesquite and huisache on grazing lands warrants evaluation of treatment life and economics of current and experimental treatments. Treatment life is defined as the time between treatment application and when canopy cover of undesirable brush returns to a competitive level with native forage grasses (i.e., 25% canopy cover for mesquite and 30% canopy cover for huisache). Treatment life of industry-standard herbicides was compared with that of aminocyclopyrachlor plus triclopyr amine (ACP+T) from 10 broadcast-applied honey mesquite and five broadcast-applied huisache trials established from 2007 through 2013 across Texas. On average, the treatment life of industry standard treatments (IST) for huisache was 3 yr. In comparison, huisache canopy cover was only 2.5% in plots treated with ACP+T 3 yr after treatment. The average treatment life of IST for honey mesquite was 8.6 yr, whereas plots treated with ACP+T had just 2% mesquite canopy cover at that time. Improved treatment life of ACP+T compared with IST life was due to higher mortality resulting in more consistent brush canopy reduction. The net present values (NPVs) of ACP+T and IST for both huisache and mesquite were similar until the treatment life of the IST application was reached (3 yr for huisache and 8.6 yr for honey mesquite). At that point, NPVs of the programs diverged as a result of brush competition with desirable forage grasses and additional input costs associated with theoretical follow-up IST necessary to maintain optimum livestock forage production. The ACP+T treatments did not warrant a sequential application over the 12-yr analysis for huisache or 20-yr analysis for honey mesquite that this research covered. These results indicate ACP+T provides cost-effective, long-term control of honey mesquite and huisache.
Species distribution models (SDMs) are statistical tools used to develop continuous predictions of species occurrence. ‘Integrated SDMs’ (ISDMs) are an elaboration of this approach with potential advantages that allow for the dual use of opportunistically collected presence-only data and site-occupancy data from planned surveys. These models also account for survey bias and imperfect detection through the use of a hierarchical modelling framework that separately estimates the species–environment response and detection process. This is particularly helpful for conservation applications and predictions for rare species, where data are often limited and prediction errors may have significant management consequences. Despite this potential importance, ISDMs remain largely untested under a variety of scenarios. We performed an exploration of key modelling decisions and assumptions on an ISDM using the endangered Baird’s tapir (Tapirus bairdii) as a test species. We found that site area had the strongest effect on the magnitude of population estimates and underlying intensity surface and was driven by estimates of model intercepts. Selecting a site area that accounted for the individual movements of the species within an average home range led to population estimates that coincided with expert estimates. ISDMs that do not account for the individual movements of species will likely lead to less accurate estimates of species intensity (number of individuals per unit area) and thus overall population estimates. This bias could be severe and highly detrimental to conservation actions if uninformed ISDMs are used to estimate global populations of threatened and data-deficient species, particularly those that lack natural history and movement information. However, the ISDM was consistently the most accurate model compared to other approaches, which demonstrates the importance of this new modelling framework and the ability to combine opportunistic data with systematic survey data. Thus, we recommend researchers use ISDMs with conservative movement information when estimating population sizes of rare and data-deficient species. ISDMs could be improved by using a similar parameterization to spatial capture–recapture models that explicitly incorporate animal movement as a model parameter, which would further remove the need for spatial subsampling prior to implementation.
Advance care planning (ACP) is identified as being an important process for people with dementia. However, its efficacy for improving outcomes relevant for the individual, carers and the health system has yet to be established.
We conducted a systematic review with the aims of testing the efficacy of ACP for people with dementia and describing the settings and population in which it has been evaluated.
A search was completed of electronic databases in August 2016. Articles were included if they described interventions aimed at increasing planning for future care of people with dementia, delivered to the person with dementia, their carers and/or health professionals.
Of 4,772 articles returned by searches, 30 met the inclusion criteria, testing interventions in nursing home (n= 16) community (n = 10) and acute care (n = 4) settings. Only 18 interventions directly involved the person with dementia, with the remainder focusing on surrogate decision-makers. In all settings, interventions were found effective in increasing ACP practice. In nursing homes, ACP was found to influence care and increase the concordance between end of life wishes and care provided. Interventions in the community were found to improve patient quality of life but were not shown to influence concordance.
Future research should focus on ways to involve people with dementia in decision-making through supported means.
We describe an algorithm that can fit the properties of the dwarf galaxy progenitor of a tidal stream, given the properties of that stream. We show that under ideal conditions (the Milky Way potential, the orbit of the dwarf galaxy progenitor, and the functional form of the dwarf galaxy progenitor are known exactly), the density and angular width of stars along the stream can be used to constrain the mass and radial profile of both the stellar and dark matter components of the progenitor dwarf galaxy that was ripped apart to create the stream. Our provisional fit for the parameters of the dwarf galaxy progenitor of the Orphan Stream indicates that it is less massive and has fewer stars than previous works have indicated.
The objective of this work was to describe treatment-emergent sexual dysfunction (TESD) and tolerability following a switch from selective serotonin reuptake inhibitor (SSRI: citalopram, paroxetine, or sertraline) monotherapy to vortioxetine or escitalopram monotherapy in adults with well-treated major depressive disorder (MDD) and SSRI-induced sexual dysfunction.
Data were analyzed from the primary study, an 8-week, randomized, double-blind, head-to-head study in which participants with well-treated depressive symptoms but experiencing TESD with SSRIs were directly switched to flexible doses (10/20 mg) of vortioxetine or escitalopram. Sexual functioning was assessed by the Changes in Sexual Functioning Questionnaire-14 (CSFQ-14), efficacy by the Montgomery–Åsberg Depression Rating Scale scores (MADRS) and Clinicians Global Impression of Severity/Improvement (CGI-S/CGI-I), and tolerability by adverse events. Efficacy and tolerability were assessed by pre-switch SSRI therapy where possible, and by participant characteristics.
Greater improvements in TESD were seen in the vortioxetine compared with escitalopram groups based on: participant demographics (≤45 years, women; P = 0.045), prior SSRI treatment (P = 0.044), number of prior major depressive episodes (MDEs) (1–3; P = 0.001), and duration of prior SSRI therapy (>1 year; P = 0.001). Prior SSRI treatment did not appear to influence the incidence or severity of TEAEs, except for nausea. Regardless of prior SSRI, both treatments maintained antidepressant efficacy after 8 weeks.
Results suggest that vortioxetine is a safe and effective switch therapy for treating SSRI-induced sexual dysfunction in adults with well-treated MDD. Also, improvement in sexual dysfunction with vortioxetine or escitalopram may be influenced by prior SSRI usage, sex, age, and history of MDEs.
Intermittent energy restriction (IER) involves short periods of severe energy restriction interspersed with periods of adequate energy intake, and can induce weight loss. Insulin sensitivity is impaired by short-term, complete energy restriction, but the effects of IER are not well known. In randomised order, fourteen lean men (age: 25 (sd 4) years; BMI: 24 (sd 2) kg/m2; body fat: 17 (4) %) consumed 24-h diets providing 100 % (10 441 (sd 812) kJ; energy balance (EB)) or 25 % (2622 (sd 204) kJ; energy restriction (ER)) of estimated energy requirements, followed by an oral glucose tolerance test (OGTT; 75 g of glucose drink) after fasting overnight. Plasma/serum glucose, insulin, NEFA, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide (GIP) and fibroblast growth factor 21 (FGF21) were assessed before and after (0 h) each 24-h dietary intervention, and throughout the 2-h OGTT. Homoeostatic model assessment of insulin resistance (HOMA2-IR) assessed the fasted response and incremental AUC (iAUC) or total AUC (tAUC) were calculated during the OGTT. At 0 h, HOMA2-IR was 23 % lower after ER compared with EB (P<0·05). During the OGTT, serum glucose iAUC (P<0·001), serum insulin iAUC (P<0·05) and plasma NEFA tAUC (P<0·01) were greater during ER, but GLP-1 (P=0·161), GIP (P=0·473) and FGF21 (P=0·497) tAUC were similar between trials. These results demonstrate that severe energy restriction acutely impairs postprandial glycaemic control in lean men, despite reducing HOMA2-IR. Chronic intervention studies are required to elucidate the long-term effects of IER on indices of insulin sensitivity, particularly in the absence of weight loss.
Examination of estimates of the income elasticity of the value of a statistical life based on international stated preference studies yields an average between 0.94 and 1.05 overall and 0.65 and 0.80 after controlling for covariates. Quantile regression estimates indicate that the income elasticity is about 0.55 for more affluent countries and 1.0 for lower income nations, i.e., those countries that have estimates of the value of a statistical life below $2 million or per capita income levels below $3212. The estimates distinguish the values of the income elasticity across country either by income level or by the value of a statistical life. These elasticities are similar to those found in revealed preference labor market studies. The estimates are robust, controlling for possible sample selection bias and the influence of covariates, such as the type of risk.
Traditional accounts of the Eighteenth and Twenty-first Amendments to the U.S. Constitution largely ignore the role of the major political parties. We argue that partisan politics was an integral part of the constitutional politics of this period. The need to manage divisions within both parties’ electoral coalitions during the transition from the third to the fourth-party systems led to the enactment of the Eighteenth Amendment without support from either national party. While most accounts trace prohibition’s demise to widespread noncompliance and the graft it generated, we argue that elite congressional support for prohibition gave way when civil service reforms removed federal prohibition agents as patronage resources. We also argue that by giving states control of designing state conventions, and thereby risking state malapportionment of conventions, Democrats succeeded in overcoming the traditional fissures that divided their southern and northern wings.
Thin film tin sulphide (SnS) was deposited on to molybdenum (Mo) substrates using metal organic chemical vapor deposition at 470°C using tetraethyltin and ditertiarybutylsulfide as precursors. In situ mass spectroscopy was used to study the exhaust gas species downstream of the reaction zone. The precursor vapor carrier gas was either nitrogen or hydrogen, thin film SnS only forming when the latter was used. Mass spectroscopy determined that hydrogen sulfide was being produced and playing a critical role in the vapor phase reaction process and adsorption of tin and sulfur on to the Mo surface. As-grown grain sizes were determined by scanning electron microscopy and were observed to be large averaging around 2 microns across. X-ray diffraction showed the films to be single phase SnS without any parasitic Sn2S3 or SnS2 phases, with a small amount of MoS2 also being detected.
Accurate and reproducible patient positioning is a critical step in radiotherapy for breast cancer. This has seen the use of permanent skin markings becoming standard practice in many centres. Permanent skin markings may have a negative impact on long-term cosmetic outcome, which may in turn, have psychological implications in terms of body image. The aim of this study was to investigate the feasibility of using a semi-permanent tattooing device for the administration of skin marks for breast radiotherapy set-up.
Materials and methods
This was designed as a phase II double-blinded randomised-controlled study comparing our standard permanent tattoos with the Precision Plus Micropigmentation (PPMS) device method. Patients referred for radical breast radiotherapy were eligible for the study. Each study participant had three marks applied using a randomised combination of the standard permanent and PPMS methods and was blinded to the type of each mark. Follow up was at routine appointments until 24 months post radiotherapy. Participants and a blind assessor were invited to score the visibility of each tattoo at each follow-up using a Visual Analogue Scale. Tattoo scores at each time point and change in tattoo scores at 24 months were analysed by a general linear model using the patient as a fixed effect and the type of tattoo (standard or research) as covariate. A simple questionnaire was used to assess radiographer feedback on using the PPMS.
In total, 60 patients were recruited to the study, of which 55 were available for follow-up at 24 months. Semi-permanent tattoos were more visible at 24 months than the permanent tattoos. Semi-permanent tattoos demonstrated a greater degree of fade than the permanent tattoos at 24 months (final time point) post completion of radiotherapy. This was not statistically significant, although it was more apparent for the patient scores (p=0·071) than the blind assessor scores (p=0·27). No semi-permanent tattoos required re-marking before the end of radiotherapy and no adverse skin reactions were observed.
The PPMS presents a safe and feasible alternative to our permanent tattooing method. An extended period of follow-up is required to fully assess the extent of semi-permanent tattoo fade.
Countries throughout the world use estimates of the value of a statistical life (VSL) to monetize fatality risks in benefit-cost analyses. However, the vast majority of countries lack reliable revealed preference or stated preference estimates of the VSL. This article proposes that the best way to calculate a population-average VSL for countries with insufficient or unreliable data is to transfer a base VSL from the United States calculated using labor market estimates from Census of Fatal Occupational Injuries data, coupled with adjustments for differences in income between the United States and the country of interest. This approach requires estimation of two critical inputs: a base U.S. VSL and the income elasticity of the VSL. Drawing upon previous meta-analyses that include adjustments for publication selection biases, we adopt a base VSL of $9.6 million. We utilize a sample of 953 VSL estimates from 68 labor market studies of the VSL covering fourteen lower-middle income to high income nations. We estimate the income elasticity of the VSL within the United States to be from 0.5 to 0.7 and to be just above 1.0 for non-U.S. countries. Quantile regression reveals that much of the disparity in income elasticities is attributable to income differences between the United States and other countries, as the income elasticity increases for lower income populations. Using income classifications from the World Bank, we calculate average VSLs in lower income, lower-middle income, upper-middle income, and upper income countries to be $107,000, $420,000, $1.2 million, and $6.4 million, respectively. We also present VSL estimates for all 189 countries for which World Bank income data are available, yielding a VSL range from $45,000 to $18.3 million.
The belief that breakfast is the most important meal of day has been derived from cross-sectional studies that have associated breakfast consumption with a lower BMI. This suggests that breakfast omission either leads to an increase in energy intake or a reduction in energy expenditure over the remainder of the day, resulting in a state of positive energy balance. However, observational studies do not imply causality. A number of intervention studies have been conducted, enabling more precise determination of breakfast manipulation on indices of energy balance. This review will examine the results from these studies in adults, attempting to identify causal links between breakfast and energy balance, as well as determining whether consumption of breakfast influences exercise performance. Despite the associations in the literature, intervention studies have generally found a reduction in total daily energy intake when breakfast is omitted from the daily meal pattern. Moreover, whilst consumption of breakfast supresses appetite during the morning, this effect appears to be transient as the first meal consumed after breakfast seems to offset appetite to a similar extent, independent of breakfast. Whether breakfast affects energy expenditure is less clear. Whilst breakfast does not seem to affect basal metabolism, breakfast omission may reduce free-living physical activity and endurance exercise performance throughout the day. In conclusion, the available research suggests breakfast omission may influence energy expenditure more strongly than energy intake. Longer term intervention studies are required to confirm this relationship, and determine the impact of these variables on weight management.
Using a combination of pollen, non-pollen palynomorphs (NPPs) and charcoal particle stratigraphies from sediment cores from two sites, along with historical records, we reconstructed paleoenvironmental change in mid-coastal California. The San Antonio Creek section contains a discontinuous, Holocene-length record, while Mod Pond includes a continuous late Holocene record. Together the records allow for interpretation of most of the present interglacial. The longer record documents coastal sage scrub and chaparral dominated by woodland elements early in the Holocene to about 9000 yr ago, a potential decline in woodland communities with drying conditions during the middle Holocene to about 4800 yr ago, and an expansion of coastal sage scrub with grassland during the late Holocene. Evidence for climatic fluctuations during the last 1000 yr at Mod Pond is equivocal, suggesting that the Medieval Climate Anomaly–Little Ice Age had modest impact on the Mod Pond environment. However, evidence of significant environmental change associated with cultural transitions in the 18th–19th centuries is stark. Introduction of non-native plants, establishment of cattle and sheep grazing, missionization of the native population, changes in burning practices during the Spanish period and enhanced cropping activities during North American settlement worked together to substantially modify the mid-California coastal landscape in about a century's time.
An inline metal organic chemical vapor deposition system was used to deposit tin sulfide at temperatures >500 °C. Tetramethyltin was used as the tin source and diethyldisulfide as the sulfur source. An overhead injector configuration was used delivering both precursors directly over the substrate. The tin and sulfur precursors were premixed before injection to improve chemical reaction in the gas phase. Growth temperatures 500 – 540 °C were employed producing films with approximate 1:1 stoichiometry of Sn and S detected by energy dispersive x-ray spectroscopy. X-ray diffraction showed there to be mixed phases with Sn2S3 present with SnS.