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Mental health services in Cambodia required rebuilding in their entirety after their destruction during conflict in the 1970s. During the late 1990s there was rapid growth and development of professional mental health training and education. Currently, basic mental healthcare is available primarily in urban areas and is provided by a mixture of government, non-government and private services. Despite the initial rapid growth of services and the development of a national mental health strategy in 2010, significant challenges remain in achieving an acceptable, standardised level of mental healthcare nationally.
Concurrent chemotherapy with radiotherapy is the standard treatment for locoregionally advanced nasopharyngeal cancer. Cetuximab can be used in the treatment of head and neck squamous cell carcinoma. However, the randomised studies that led to approval for its use in this setting excluded nasopharyngeal cancer. In the context of limited data for the use of cetuximab in nasopharyngeal cancer in the medical literature, this review aimed to summarise the current evidence for its use in both primary and recurrent or metastatic disease.
A literature search was performed using the keywords ‘nasopharyngeal neoplasm’, ‘cetuximab’ and ‘Erbitux’.
Twenty studies were included. There were no randomised phase III trials, but there were nine phase II trials. The use of cetuximab in the treatment of nasopharyngeal carcinoma has been tested in various settings, including in combination with induction chemotherapy and concurrent chemoradiotherapy, and in the palliative setting.
There is no evidence of benefit from the addition of cetuximab to standard management protocols, and there is some evidence of increased toxicity. There is more promise for its use in metastatic or locally recurrent settings. This review draws together the existing evidence and could provide a focus for future studies.
Evidence from the literature shows that clinicians’ knowledge of rules and legislation surrounding driving can often be poor. A closed-loop audit was conducted to gauge the level of driving advice given to patients with dizziness.
The clinical notes of 100 patients referred to the vertigo clinic at a tertiary referral centre were retrospectively searched for evidence of driving advice. Education sessions were undertaken and a patient information leaflet was developed before a second cycle of the audit.
Results and conclusion
The proportion of patients having documented evidence of receiving driving advice increased from 6.3 per cent to 10.4 per cent. It is therefore clear that, despite this improvement, a significant proportion of patients’ notes did not contain documentation about driving. This is likely because of many reasons, including individual interpretation by clinicians. This paper provides a reminder of the rules, and discusses their interpretation and implementation in an increasingly medicolegal environment.
Born into a kingdom where the king prohibited female inheritance, the eponymous heroine of the thirteenth–century Old French romance Silence was raised as a boy, much to the frustration of Nature and satisfaction of Nurture. Silence's education in masculine courtly behaviour and in the arts of war as her father's only heir was so successful that ‘He (sic) [became] … a valiant and noble knight;/ no king or count was ever better’ (‘Chevaliers est vallans et buens,/ Mellor n'engendra rois ne cuens’). Silence's true gender was only unmasked when he/she captured the prophet Merlin, who could only be seized if tricked by a woman. At the end of the tale, Nature recovered ‘her rights’ (‘sa droiture’) over Silence's body and restored her feminine appearance, whereupon Silence, who became known as Silentia rather than Silentius, abandoned her masculine knightly attire and married the king.
With its focus on violence, power and knighthood, chivalry appears first and foremost as a masculine social ideal in both medieval literature and life. Carrying arms and engaging personally in knightly forms of combat were male preserves; it was unnatural for women to participate in them. As Nature admonished Silence, before she reassumed her true gender:
‘It's a very nasty thing you're doing to me, leading this sort of life.
You [as a woman] have no business going off into the forest, jousting, hunting, shooting off arrows.
Desist from all of this!’ …
‘Go to a chamber and learn to sew!’
Yet the centrality of aristocratic ladies to courtly life and lordship allowed women to participate in chivalric culture in ways that were not entirely divorced from those of their male kin. Although women often featured in romances as lovers or unattainable figures for whom aristocratic men performed various feats of arms, they also appeared as agents, rather than as purely passive recipients of male affection or admiration. This chapter considers how far chivalric practices, values and modes of conduct were gendered, and explores how far female experiences differed from those of men between the twelfth and early fourteenth centuries. It adopts a broad definition of chivalry that encompasses the lifestyles and ideals of behaviour of those persons who belonged to the aristocracy. It also recognises that chivalric literature was interwoven with gendered ideas and stereotypes that reflected many of the tenets of elite society.
To verify the previously untested assumption that eating more salad enhances vegetable intake and determine if salad consumption is in fact associated with higher vegetable intake and greater adherence to the Dietary Guidelines for Americans (DGA) recommendations.
Individuals were classified as salad reporters or non-reporters based upon whether they consumed a salad composed primarily of raw vegetables on the intake day. Regression analyses were applied to calculate adjusted estimates of food group intakes and assess the likelihood of meeting Healthy US-Style Food Pattern recommendations by salad reporting status.
Cross-sectional analysis of data collected in 2011–2014 in What We Eat in America, the dietary intake component of the National Health and Nutrition Examination Survey.
US adults (n 9678) aged ≥20 years (excluding pregnant and lactating women).
On the intake day, 23 % of adults ate salad. The proportion of individuals reporting salad varied by sex, age, race, income, education and smoking status (P<0·001). Compared with non-reporters, salad reporters consumed significantly larger quantities of vegetables (total, dark green, red/orange and other), which translated into a two- to threefold greater likelihood of meeting recommendations for these food groups. More modest associations were observed between salad consumption and differences in intake and likelihood of meeting recommendations for protein foods (total and seafood), oils and refined grains.
Study results confirm the DGA message that incorporating more salads in the diet is one effective strategy (among others, such as eating more cooked vegetables) to augment vegetable consumption and adherence to dietary recommendations concerning vegetables.
The Kabwe Zn-Pb deposit (central Zambia) consists of a cluster of mixed sulfide and non-sulfide orebodies. The sulfide ores comprise sphalerite, galena, pyrite, chalcopyrite and accessory Ge-sulfides (±Ga and In). The non-sulfide ores comprise: (1) willemite-dominated zones encasing massive sulfide orebodies and (2) oxide-dominated alteration bands, overlying both the sulfide and Zn-silicate orebodies. This study focuses on the Ge, In and Ga distribution in the non-sulfide mineralization, and was carried out on a suite of Kabwe specimens, housed in the Natural History Museum Ore Collection (London). Petrography confirmed that the original sulfides were overprinted by at least two contrasting oxidation stages dominated by the formation of willemite (W1 and W2), and a further event characterized by weathering-related processes. Oxygen isotopic analyses have shown that W1 and W2 are unrelated genetically and furthermore not related to supergene Zn-Pb-carbonates in the oxide-dominated assemblage. The δ18O composition of 13.9–15.7‰ V-SMOW strongly supports a hydrothermal origin for W1. The δ18O composition of W2 (−3.5‰ to 0‰ V-SMOW) indicates that it precipitated from groundwaters of meteoric origin in either a supergene or a low-T hydrothermal environment. Gallium and Ge show a diversity of distribution among the range of Zn-bearing minerals. Gallium has been detected at the ppm level in W1, sphalerite, goethite and hematite. Germanium occurs at ppm levels in W1 and W2, and in scarcely detectable amounts in hemimorphite, goethite and hematite. Indium has low concentrations in goethite and hematite. These different deportments among the various phases are probably due to the different initial Ga, In and Ge abundances in the mineralization, to the different solubilities of the three elements at different temperatures and pH values, and finally to their variable affinities with the various minerals formed.
Macroscopic algae can be found in large open ponds or harvested from the sea. Macro algae includes three distinct groups based on colour: green, brown and red. They are unique in containing secondary metabolites that can be extracted and used for various purposes. This review examines the antimicrobial properties (bacteria, viruses and fungi) of macro algae and its extracts to improve poultry health and performance. This includes body weight gain, feed conversion efficiency and carcass yield improvements in broilers and egg weight and shell quality in layers. As an example, in one study, 35-day body weight of broilers was increased 7.6% with the inclusion of 0.5% Undaria pinnatifida (brown macroalgae) to the diet. The investigations discussed show the diversity of the species available and broad scope where research has been done and the potential for the future.
The drive to increase the output of animal product in some sectors of ruminant livestock production has led to greater use of feeds such as cereal grains and soyabean meal that are potentially human-edible. This trend has caused concern since, by so doing, ruminants compete not only with monogastric livestock but also with the human population for a limited global area of cultivatable land on which to produce grain crops. Reasons for using potentially human-edible feeds in ruminant diets include increased total daily energy intake, greater supply of essential amino acids and improved ruminal balance between fermentable energy and degradable protein. Soyabean meal, produced on land that has been in arable cultivation for many years can fulfil a useful role as a supplier of undegraded dietary protein in diets for high-yielding dairy cows. However, in the context of sustaining the production of high-quality foods from livestock to meet the demands of a growing human population, the use of potentially human-edible feed resources by livestock should be restricted to livestock with the highest daily nutrient requirements; that is, potentially human-edible feed inputs should be constrained to meeting requirements for energy and protein and to rectifying imbalances in nutrient supply from pastures and forage crops such as high concentrations of nitrogen (N). There is therefore a role for human-edible feeds in milk production because forage-only systems are associated with relatively low output per head and also low N use efficiency compared with systems with greater reliance on human-edible feeds. Profitability on farm is driven by control of input costs as well as product value and examples are given of low-cost bovine milk and meat production with little or no reliance on potentially human-edible feeds. In beef production, the forage-only systems currently under detailed real-time life-cycle analysis at the North Wyke Farm Platform, can sustain high levels of animal growth at low feed cost. The potential of all-forage diets should be demonstrated for a wide range of ruminant milk and meat production systems. The challenge for the future development of ruminant systems is to ensure that potentially human-edible feeds, or preferably human-inedible by-products if available locally, are used to complement pastures and forage crops strategically rather than replace them.
This chapter investigates the archaeological landscapes of the frontiers of the Sasanian Empire. Drawing on evidence from current and archived archaeological surveys, in combination with high-resolution remote sensing datasets such as CORONA spy photography, we compare the organisation of settlements and defensive structures of the Sasanian frontier zones in response to a variety of external pressures. These varied from the Roman Empire in the west to less centralised entities, including nomadic groups, in the southwest and north-east. Following a general discussion of the multiple manifestations of Sasanian frontiers drawn from southern Mesopotamia (Iraq), northern Syria and north-eastern Iran, the main focus of the chapter is on the complex frontier landscape of the southern Caucasus, particularly the area of modern Azerbaijan, Georgia and Daghestan. We discuss the role of linear barriers, including the Gorgan Wall in north-eastern Iran and the Ghilghilchay and Derbent Walls in the Caucasus, irrigation systems, and alignments of fortifications and settlements in shaping their local landscapes. By placing the archaeological remains of the Sasanian Empire in a wider context we are able to examine the relationships between military installations, settlement patterns, infrastructure and geographical features such as mountain ranges and rivers. Comparing the different case studies allows us to conclude with some general statements on the nature of Sasanian power in the frontier territories of the empire.
As a large territorial entity, the Sasanian Empire encompassed a variety of geographical, environmental and socio-cultural zones. Even within the northern and western reaches discussed here, the empire included the high mountain ranges of the Taurus, Caucasus and eastern Anatolia, the fertile dry farming plains of much of northern Mesopotamia and Gorgan, heavily irrigated southern Mesopotamia and steppe and desert regions in various guises (Fig. 5.1). Threats to Sasanian power were similarly diverse, from the agrarian might of the Roman Empire in the west to smaller local ‘states’, client kingdoms and decentralised nomadic groups in the north and north-east. This diversity had a profound impact on the organisation and character of the frontier regions at the edges of imperial control. In this chapter we make use of data acquired as part of the recent upsurge in interest in Sasanian frontiers across the study region,1 as well as satellite imagery and textual information, to examine the structure and function of the frontier zones in different areas.
To prospectively assess treatment outcomes of chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery and post-operative medical treatment over a prolonged follow-up period.
Patients undergoing functional endoscopic sinus surgery in the tertiary referral practice of a single surgeon were studied prospectively. Symptoms were scored by patients pre-operatively and over a minimum follow-up period of 12 months.
The study comprised 200 non-consecutive patients. The median pre-operative symptom score was 16 (out of a maximum of 25) (95 per cent confidence interval = 15 to 17). Symptom scores reduced to a median of 7 (95 per cent confidence interval = 6 to 8) after 12 months of follow up (p < 0.0001). The median symptom score improved for all symptoms and across all patient subgroups.
Extensive functional endoscopic sinus surgery offers significant and durable symptom improvement in patients with chronic rhinosinusitis refractory to medical treatment. This improvement extends to all patient subgroups. Prolonged medical therapy is recommended after functional endoscopic sinus surgery.
There is increasing recognition that perinatal anxiety disorders are both common and potentially serious for mother and child. Obsessive–compulsive disorder (OCD) can be triggered or exacerbated in the postpartum period, with mothers reporting significant effects on parenting tasks. However, there is little evidence concerning their effective treatment or the impact of successful treatment on parenting.
A total of 34 mothers with OCD and a baby of 6 months old were randomized into either time-intensive cognitive–behaviour therapy (iCBT) or treatment as usual (TAU). iCBT took place after randomization at 6 months postpartum and was completed by 9 months. Maternal symptomatology, sensitivity in mother–infant interactions and parenting were assessed at baseline and reassessed at 12 months postpartum. At 12 months attachment was also assessed using Ainsworth's Strange Situation Procedure. A healthy control group of mothers and infants (n = 37) underwent the same assessments as a benchmark.
iCBT was successful in ameliorating maternal symptoms of OCD (controlled effect size = 1.31–1.90). However, mother–infant interactions were unchanged by treatment and remained less sensitive in both OCD groups than a healthy control group. The distribution of attachment categories was similar across both clinical groups and healthy controls with approximately 72% classified as secure in each group.
iCBT is an effective intervention for postpartum OCD. Sensitive parenting interactions are affected by the presence of postpartum OCD and this is not improved by successful treatment of OCD symptoms. However, the overall attachment bond appears to be unaffected. Longitudinal studies are needed to explore the impact of postpartum OCD as the child develops.
We prove that, for Poisson transmission and recovery processes, the classic susceptible→infected→recovered (SIR) epidemic model of Kermack and McKendrick provides, for any given time t>0, a strict lower bound on the expected number of susceptibles and a strict upper bound on the expected number of recoveries in the general stochastic SIR epidemic. The proof is based on the recent message passing representation of SIR epidemics applied to a complete graph.
CVD accounted for 27 % of all deaths in the UK in 2014, and was responsible for 1·7 million hospital admissions in 2013/2014. This condition becomes increasingly prevalent with age, affecting 34·1 and 29·8 % of males and females over 75 years of age respectively in 2011. The dysregulation of cholesterol metabolism with age, often observed as a rise in LDL-cholesterol, has been associated with the pathogenesis of CVD. To compound this problem, it is estimated by 2050, 22 % of the world's population will be over 60 years of age, in culmination with a growing resistance and intolerance to pre-existing cholesterol regulating drugs such as statins. Therefore, it is apparent research into additional therapies for hypercholesterolaemia and CVD prevention is a growing necessity. However, it is also imperative to recognise this complex biological system cannot be studied using a reductionist approach; rather its biological uniqueness necessitates a more integrated methodology, such as that offered by systems biology. In this review, we firstly discuss cholesterol metabolism and how it is affected by diet and the ageing process. Next, we describe therapeutic strategies for hypercholesterolaemia, and finally how the systems biology paradigm can be utilised to investigate how ageing interacts with complex systems such as cholesterol metabolism. We conclude by emphasising the need for nutritionists to work in parallel with the systems biology community, to develop novel approaches to studying cholesterol metabolism and its interaction with ageing.
A range of options was explored to test the hypothesis that diets for dairy cows could be formulated to reduce the carbon footprint (CFP) of feed, increase efficiency of conversion of potentially human-edible feed into milk, increase nitrogen use efficiency (NUE) and reduce methane (CH4) emissions per kg milk. Diets based on grazed grass, grass silage, maize silage or straw, supplemented with raw material feeds, were formulated to meet requirements for metabolizable energy and metabolizable protein for a range of daily milk yields. At similar levels of milk yield, NUE, predicted CH4 emissions and diet CFP were generally higher for diets based on maize silage than for those based on grazed grass, grass silage or straw. Predicted CH4 emissions and human-edible proportion decreased, while NUE increased with the increasing level of milk yield. It is concluded that there is potential to reduce the environmental impact of milk production by altering diet formulation, but the extent to which this might occur is likely to depend on availability of raw material feeds with low CFPs.