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When airway management is indicated, to avoid a bad outcome, patient safety will be maximised by careful decision making about and careful implementation of the chosen approach. This chapter addresses planning for the safest approach to securing the airway by assessing the patient for anatomical and physiological predictors of difficulty with airway management. When such difficulty is predicted, awake tracheal intubation will often provide the best margin of safety; indications for the procedure are discussed. Equally, when technical difficulty is predicted, the pre-conditions required to safely proceed with airway management after the induction of general anaesthesia are addressed. Predicted or not, difficulty encountered with tracheal intubation or supraglottic airway use in the unconscious patient must be met with a methodical and stepwise approach. This includes calling for help, maintaining patient oxygenation and methodically proceeding from one device type or technique to another, thus avoiding multiple futile attempts with the same device. Failure of a maximum of three attempts at the intended technique (most often tracheal intubation or use of a supraglottic airway) should be taken as an indication to refrain from further attempts, call for help, maintain patient oxygenation and reassess the plan for next steps. Finally, a ‘cannot intubate, cannot oxygenate’ situation is defined by the failure to successfully oxygenate the patient with all of tracheal intubation, face mask ventilation or a supraglottic airway and requires prompt front of neck airway access (‘surgical airway’).
Little is known about parents’ compensatory health beliefs (CHB) surrounding their children’s engagement in physical activity (PA). Our aim was to provide evidence regarding the nature of, and factors underpinning, parents’ PA-related compensatory beliefs for their children.
A qualitative descriptive approach and thematic content analysis were employed.
Parents were recruited from community sport and PA programmes.
Eighteen parents aged 32–52 years (mean age = 40·8 (sd 5·4) years; six males; twelve females).
Analyses indicated that parents compensate through ‘passive’ or ‘active’ means. Among parents who compensated, most described their provision of ‘treat’ foods/drinks and a minority described allowing extended sedentary time to their children. Parents’ reasons underpinning these beliefs related to their child’s general physical/health status and psychological characteristics, and their own motivation and mood state.
These findings provide the first evidence of unhealthy dietary and sedentary behaviour CHB that parents may hold regarding their children’s involvement in PA.
Cardiac disease has been the leading cause of overall maternal mortality in the UK since the 2002–2004 triennium. The maternal death rate from cardiac disease has increased from 1.65 per 100,000 maternities in the 1997–1999 triennium to 2.34 per 100,000 maternities in the 2013–2015 triennium. This is thought to be due to increasing maternal age, increasing levels of obesity and better recognition of cardiac pathology at autopsy.
Professor Liu, President of Shenzhen Kangning Hospital, came to Canada in 2008 and learned that Assertive Community Treatment Team (hospital without walls) might be one of the solutions to the shortage of inpatient beds. I was invited to conduct site visits, consultations, training sessions and workshops for the mental health professionals in Shenzhen since 2009. Doctors and administrative staff from Shenzhen were sent to Toronto, Canada to learn about the program implementation. Finally the Shenzhen ACT in China was established in November 2012.
To describe the development and adaptation of ACT model in Shenzhen China. To report the success and challenges of ACTT development in China.
To define the history and the purpose, its principles, its internal structure, the team composition, team dynamics, the target population, its characteristics of Shenzhen ACT within the demographic context. I will share my subjective experience regarding my observation, my perspectives and a brief comparison with ACT Teams in Toronto, Canada will be highlighted.
The China Shenzhen ACT Team was born in an institutional context where the community mental health care was still novel and not having enough infrastructures to support the work.
The Shenzhen ACT Team is the first ACT in China to experience the effectiveness and efficiency in taking care of severe mentally ill patients in the community. They have successfully implemented ACT service with the support from the hospital, municipal government and the neighbourhood community.
This paper investigates the recidivism of Mount Sinai Hospital mental health court support program in Toronto, Canada among patients involved in the criminal justice system. It also looks to find relationships between recidivism and factors including gender, age and ethnicity.
Follow up periods of up to 48 months after the time of initial admission to the program was conducted and the frequency of re-offense was observed. Comparisons for the significance of risk factors were analyzed using t-tests and Chisquare tests.
191 clients were admitted to the Mount Sinai Hospital Court Support Program between September 2001 and June 2007. At first admission, the mean ± s.d. age was 35.8 ± 9.8 years (range=18-74 years; n=184). The median age was 35 years. The modal age was 34 years. Of the 191 clients, 16 (8.4%) reoffended. Two of them (12.5%) had a third offense; and 1 (6.3%) had a total of four offenses within this tracking period. it appears that re-offense is more likely between 13 and 24 months. No re-offense was noted beyond the 48 months. The gender distribution was not significantly different between reoffenders and non-reoffenders. The mean age at first admission also did not differ between reoffenders and non-reoffenders. The distribution of ethnic groups among reoffenders and non-reoffenders did not differ.
The findings seem to indicate that recidivism has no relationship with gender, age and ethnic groups. The comprehensive and length of support services seem more important in preventing recidivism.
Continued reliance on chemical methods for controlling annual bluegrass has resulted in many populations evolving resistance to PRE and POST herbicides, particularly in warm-season turfgrass species such as zoysiagrass. Soil seedbank management is critically important when managing herbicide-resistant weeds. Fraise mowing (also spelled fraze, frase, and fraize) is a new turfgrass cultivation practice designed to remove aboveground biomass while allowing turf to regrow vegetatively. We hypothesized that this process would remove annual bluegrass seed and therefore be a mechanical means of controlling annual bluegrass in turfgrass. Zoysiagrass field plots were fraise-mowed in June 2015 only, June 2016 only, June 2015 and June 2016, or left untreated. The fraise mower was configured to remove the uppermost 25 mm of plot surface (i.e., 15-mm verdure and 10-mm soil). Annual bluegrass infestation was quantified in April following fraise mowing via grid count. Soil cores (10.8 cm diameter) were extracted from each plot after grid count data were collected to assess effects of fraise mowing on the soil seedbank. Moreover, replicated subsamples (7.6 L) of debris generated during fraise mowing were collected to better understand weed seed content removed during the fraise mowing process. Fraise mowing in June offered a slight reduction (24%) in annual bluegrass cover the following April. Whereas 28% of the seed in fraise-mowing debris consisted of annual bluegrass, there was no difference in the quantity of annual bluegrass seed remaining in the soil seedbank among fraise-mowed and non–fraise-mowed plots. Although fraise mowing may help to temporarily reduce existing annual bluegrass infestations via mechanical removal, the frequency and depth we studied did not effectively reduce the seedbank. Fraise mowing is a useful tool for providing mechanical suppression of annual bluegrass but it is not a replacement for properly timed herbicide applications.
Red meat is an important dietary source of protein and many other essential nutrients including omega(n)-3 polyunsaturated fatty acids (PUFA) which provide numerous benefits to human health. It is well known that grass-fed meat contains a more favourable fatty acid profile, compared to other feeding regimes, but the feasibility of grass finishing is in decline for many farmers/producers. Therefore, alternative methods to enhance the fatty acid profile of red meats, such as beef, are needed to meet increasing consumer demands for ‘healthier’ products. This study compared plasma PUFA concentrations across cattle finished on three different feeding regimes. Three farms supplied livestock to the current study, where cattle were fed three different feeding regimes for a minimum of 15-weeks prior to slaughter. Feeding regimes were ad lib concentrate (negative control), n3-enriched ad lib concentrate (treatment) or grass-fed only (positive control). Blood was collected at slaughter into EDTA tubes and plasma aliquots were stored at -80°C until analysis. A validated gas chromatography–mass spectrometry (GC-MS) method was used to quantify individual PUFA concentrations in mg/ml [linoleic acid (LA); arachidonic acid (AA); alpha-linolenic acid (ALA); eicosapentaenoic acid (EPA); docosapentaenoic acid (DPA); docosahexaenoic acid (DHA)]. Samples from 23, 49 and 40 animals (in control, treatment & grass groups, respectively) were available for the current analysis. One-way ANOVA tests revealed significant differences between groups in all PUFA concentrations quantified (all P < 0.026). Post-hoc (LSD) tests showed mean ± SD n3 PUFA concentrations were significantly different within all three groups (all P < 0.04), increasing from negative control (0.049 ± 0.013 mg/ml), to treatment (0.095 ± 0.034 mg/ml) and grass-fed groups (0.461 ± 0.132 mg/ml). The opposite was observed for mean ± SD n6 PUFA concentrations (1.060 ± 0.297 vs. 0.918 ± 0.267 vs. 0.355 ± 0.085 mg/ml, respectively; all P < 0.02). Cattle finished on either treatment or grass regimes had a more favourable n6:n3 PUFA ratio, compared to negative control (11.98 and 0.79 vs. 22.65, respectively). This study demonstrates that the finishing diet can impact plasma PUFA concentrations of beef cattle. Animals finished on the n3-enriched concentrate had, on average, double the total n3 PUFA concentrations, as well as an improved n6:n3 ratio, compared to control cattle. These results provide preliminary data on an alternative n3-enriched feeding regime for beef cattle to improve PUFA concentrations. Further research, however, is required to confirm if such beneficial changes are also observed in bovine muscle, which would have direct benefits for consumers.
Cardiac Fibromas are primary cardiac tumours more common in children than in adults. Surgical intervention is often not required except in the case of limited cardiac output or significant arrhythmia burden. We present a symptomatic 3-month-old infant who had successful surgical intervention for a giant right ventricle fibroma found on prenatal imaging.
Maternal inflammation in early pregnancy has been identified epidemiologically as a prenatal pathogenic factor for the offspring's later mental illness. Early newborn manifestations of the effects of maternal inflammation on human fetal brain development are largely unknown.
Maternal infection, depression, obesity, and other factors associated with inflammation were assessed at 16 weeks gestation, along with maternal C-reactive protein (CRP), cytokines, and serum choline. Cerebral inhibition was assessed by inhibitory P50 sensory gating at 1 month of age, and infant behavior was assessed by maternal ratings at 3 months of age.
Maternal CRP diminished the development of cerebral inhibition in newborn males but paradoxically increased inhibition in females. Similar sex-dependent effects were seen in mothers' assessment of their infant's self-regulatory behaviors at 3 months of age. Higher maternal choline levels partly mitigated the effect of CRP in male offspring.
The male fetal-placental unit appears to be more sensitive to maternal inflammation than females. Effects are particularly marked on cerebral inhibition. Deficits in cerebral inhibition 1 month after birth, similar to those observed in several mental illnesses, including schizophrenia, indicate fetal developmental pathways that may lead to later mental illness. Deficits in early infant behavior follow. Early intervention before birth, including prenatal vitamins, folate, and choline supplements, may help prevent fetal development of pathophysiological deficits that can have life-long consequences for mental health.
High-resolution Chirp sub-bottom data were obtained offshore from the Northern Channel Islands (NCI), California, to image submerged paleoshorelines and assess local uplift rates. Although modern bathymetry is often used for modeling paleoshorelines, Chirp data image paleoshorelines buried beneath sediment that obscures their seafloor expression. The NCI were a unified landmass during the last glacial maximum (LGM; ~20 ka), when eustatic sea level was ~120 m lower than present. We identified seven paleoshorelines, ranging from ~28 to 104 m in depth, across this now-submerged LGM platform. Paleoshoreline depths were compared to local sea-level curves to estimate ages, which suggest that some were reoccupied over multiple sea-level cycles. Additionally, previous studies determined conflicting uplift rates for the NCI, ranging from 0.16 to 1.5 m/ka. Our results suggest that a rate on the lower end of this range better fits the observed submerged paleoshorelines. Using the uplift rate of ~0.16 m/ka, we estimate that paleoshorelines formed during Marine Oxygen Isotope Stage 3, the LGM, and the Younger Dryas stade are preserved on the NCI platform. These results help clarify uplift rates for the NCI and illustrate the importance of sub-bottom data for mapping submerged paleoshorelines.
Significant inter-centre variability in the intensity of endomyocardial biopsy surveillance for rejection following paediatric cardiac transplantation has been reported. Our aim was to determine if low-intensity biopsy surveillance with two scheduled biopsies in the first year would produce outcomes similar to published registry outcomes.
A retrospective study of paediatric recipients transplanted between 2008 and 2014 using a low-intensity biopsy protocol consisting of two surveillance biopsies at 3 and 12–13 months in the first post-transplant year, then annually thereafter. Additional biopsies were performed based on echocardiographic and clinical surveillance. Excluded were recipients that were re-transplanted or multi-organ transplanted or were followed at another institution.
A total of 81 recipients in the first 13 months after transplant underwent an average of 2 (SD ± 1.3) biopsies, 24 ± 6.8 echocardiograms, and 17 ± 4.4 clinic visits per recipient. During the 13-month period, 19 recipients had 24 treated rejection episodes, with the first at an average of 2.8 months post-transplant. The 3-, 12-, 36-, and 60-month conditional on discharge graft survival were 100%, 98.8%, 98.8%, and 90.4%, respectively, comparable to reported figures in major paediatric registries. At a mean follow-up of 4.7 ± 2.1 years, four patients (4.9%) developed cardiac allograft vasculopathy, three (3.7%) developed a malignancy, and seven (8.6%) suffered graft loss.
Rejection surveillance with a low-intensity biopsy protocol demonstrated similar intermediate-term outcomes and safety measures as international registries up to 5 years post-transplant.
Introduction: Ureteral colic is a common painful disorder. Early surgical intervention is an attractive management option but existing evidence does not clarify which patients benefit. Based on lack of evidence, current national specialty guidelines provide conflicting recommendations regarding who is a candidate for early intervention. We compared treatment failure rates in patients receiving early intervention to those in patients offered spontaneous passage to identify subgroups that benefit from early intervention. Methods: We used administrative data and structured chart review to study consecutive patients attending one of nine hospitals in two provinces with an index emergency department (ED) visit and a confirmed 2.0-9.9 mm ureteral stone. We described patient, stone and treatment variables, and used multivariable regression to identify factors associated with treatment failure, defined as the need for rescue intervention or hospitalization within 60 days. Our secondary outcome was ED revisit rate. Results: Overall, 1168 (37.9%) of 3081 eligible patients underwent early intervention. Patients with small stones <5mm experienced more treatment failures (31.5% v. 9.9%) and more ED revisits (38.5% v. 19.7%) with early intervention than with spontaneous passage. Patients with large stones ≥7.0mm experienced fewer treatment failures (34.7% v. 58.6%) and similar ED revisit rates with early intervention. Patients with intermediate-sized 5.0-6.9mm stones had fewer treatment failures with intervention (37.4% v. 55.5%), but only if stones were in the proximal or middle ureter. Conclusion: This study clarifies stone characteristics that identify patients likely to benefit from early intervention. We recommend low-risk patients with uncomplicated stones <5mm generally undergo initial trial of spontaneous passage, while high-risk patients with proximal or middle stones >5mm, or any stone >7mm, be offered early intervention.
Introduction: The optimal initial management approach for ureteral colic is unclear. Guidelines recommend spontaneous passage for most patients, but early stone intervention may rapidly terminate acute episodes. We compared 60-day treatment failure rates in matched patients undergoing early intervention versus spontaneous passage. Methods: We used administrative data and structured chart review to study all emergency department (ED) patients at nine Canadian hospitals who had an index ureteral colic visit and a computed tomography (CT) confirmed 2.0-9.9 mm stone during 2014. Using Cox Proportional Hazards models, we assessed 60-day treatment failure, defined as hospitalization or rescue intervention, in patients undergoing early intervention compared to propensity-score matched controls undergoing trial of spontaneous passage. Results: From 3,081 eligible patients, mean age 51 years and 70% male, we matched 577 patients in each group (total 1154). Control and intervention cohorts were balanced on all parameters and propensity scores, which reflect the conditional probability a patient would undergo early intervention, were similarly distributed. In the time to event analysis, 21.8% in both groups experienced the composite primary outcome of treatment failure (difference = 0%; 95% CI, -4.8 to 4.8%). Early intervention patients required more ED revisits (36.1% v. 25.5%; difference 10.6%; 95% CI 5.3 to 15.9%) and more 60-day hospitalizations (20.1% v. 12.8%). The strongest predictors of adverse outcome were stone size, proximal or middle stone location, and ED length of stay. Conclusion: If applied broadly to patients with 2.0-9.9mm ureteral stones, an early interventional approach was associated with similar rates of treatment failure, but more hospitalizations and emergency revisits. Research clarifying subgroups most likely to benefit will facilitate better targeting of early intervention, potentially reducing patient morbidity and improving system utilization.
Consumption of diets containing medium-chain TAG (MCT) has been shown to confer neuroprotective effects. We aim to identify the global metabolic perturbations associated with consumption of a ketogenic diet (medium-chain TAG diet (MCTD)) in dogs with idiopathic epilepsy. We used ultra-performance liquid chromatography-MS (UPLC-MS) to generate metabolic and lipidomic profiles of fasted canine serum and made comparisons between the MCTD and standardised placebo diet phases. We identified metabolites that differed significantly between diet phases using metabolite fragmentation profiles generated by tandem MS (UPLC–MS/MS). Consumption of the MCTD resulted in significant differences in serum metabolic profiles when compared with the placebo diet, where sixteen altered lipid metabolites were identified. Consumption of the MCTD resulted in reduced abundances of palmitoylcarnitine, octadecenoylcarnitine, stearoylcarnitine and significant changes, both reduced and increased abundances, of phosphatidylcholine (PC) metabolites. There was a significant increase in abundance of the saturated C17 : 0 fatty acyl moieties during the MCTD phase. Lysophosphatidylcholine (17 : 0) (P=0·01) and PC (17:0/20:4) (P=0·03) were both significantly higher in abundance during the MCTD. The data presented in this study highlight global changes in lipid metabolism, and, of particular interest, in the C17 : 0 moieties, as a result of MCT consumption. Elucidating the global metabolic response of MCT consumption will not only improve the administration of current ketogenic diets for neurological disease models but also provides new avenues for research to develop better diet therapies with improved neuroprotective efficacies. Future studies should clarify the involvement and importance of C17 : 0 moieties in endogenous MCT metabolic pathways.
The supplementing of sow diets with lipids during pregnancy and lactation has been shown to reduce sow condition loss and improve piglet performance. The aim of this study was to determine the effects of supplemental palm oil (PO) on sow performance, plasma metabolites and hormones, milk profiles and pre-weaning piglet development. A commercial sow ration (C) or an experimental diet supplemented with 10% extra energy in the form of PO, were provided from day 90 of gestation until weaning (24 to 28 days postpartum) in two groups of eight multiparous sows. Gestation length of PO sows increased by 1 day (P<0.05). Maternal BW changes were similar throughout the trial, but loss of backfat during lactation was reduced in PO animals (C: −3.6±0.8 mm; PO: −0.1±0.8 mm; P<0.01). Milk fat was increased by PO supplementation (C day 3: 8.0±0.3% fat; PO day 3: 9.1±0.3% fat; C day 7: 7.8±0.5% fat; PO day 7: 9.9±0.5% fat; P<0.05) and hence milk energy yield of PO sows was also elevated (P<0.05). The proportion of saturated fatty acids was greater in colostrum from PO sows (C: 29.19±0.31 g/100 g of fat; PO: 30.77±0.36 g/100 g of fat; P<0.01). Blood samples taken on 105 days of gestation, within 24 h of farrowing, day 7 of lactation and at weaning (28±3 days post-farrowing) showed there were no differences in plasma concentrations of triacylglycerol, non-esterified fatty acids, insulin or IGF-1 throughout the trial. However, circulating plasma concentrations of both glucose and leptin were elevated during lactation in PO sows (P<0.05 and P<0.005, respectively) and thyroxine was greater at weaning in PO sows (P<0.05). Piglet weight and body composition were similar at birth, as were piglet growth rates throughout the pre-weaning period. A period of 7 days after birth, C piglets contained more body fat, as indicated by their lower fat-free mass per kg (C: 66.4±0.8 arbitrary units/kg; PO: 69.7±0.8 arbitrary unit/kg; P<0.01), but by day 14 of life this situation was reversed (C: 65.8±0.6 arbitrary units/kg; PO: 63.6±0.6 arbitrary units/kg; P<0.05). Following weaning, PO sows exhibited an increased ratio of male to female offspring at their subsequent farrowing (C: 1.0±0.3; PO: 2.2±0.2; P<0.05). We conclude that supplementation of sow diets with PO during late gestation and lactation appears to increase sow milk fat content and hence energy supply to piglets. Furthermore, elevated glucose concentrations in the sow during lactation may be suggestive of impaired glucose homoeostasis.
As part of further investigations into three linked haemorrhagic fever with renal syndrome (HFRS) cases in Wales and England, 21 rats from a breeding colony in Cherwell, and three rats from a household in Cheltenham were screened for hantavirus. Hantavirus RNA was detected in either the lungs and/or kidney of 17/21 (81%) of the Cherwell rats tested, higher than previously detected by blood testing alone (7/21, 33%), and in the kidneys of all three Cheltenham rats. The partial L gene sequences obtained from 10 of the Cherwell rats and the three Cheltenham rats were identical to each other and the previously reported UK Cherwell strain. Seoul hantavirus (SEOV) RNA was detected in the heart, kidney, lung, salivary gland and spleen (but not in the liver) of an individual rat from the Cherwell colony suspected of being the source of SEOV. Serum from 20/20 of the Cherwell rats and two associated HFRS cases had high levels of SEOV-specific antibodies (by virus neutralisation). The high prevalence of SEOV in both sites and the moderately severe disease in the pet rat owners suggest that SEOV in pet rats poses a greater public health risk than previously considered.
Seed-dispersal ecology in tropical montane forests (TMF) differs in some predictable ways from tropical lowland forests (TLF). Environmental, biogeographic and biotic factors together shape dispersal syndromes which in turn influence forest structure and community composition. Data on diaspore traits along five elevational gradients from forests in Thailand, the Philippines, Tanzania, Malawi and Nigeria showed that diaspore size decreases with increasing altitude, fleshy fruits remain the most common fruit type but the relative proportion of wind-dispersed diaspores increases with altitude. Probably corresponding to diaspore size decreasing with increasing elevation, we also provide evidence that avian body size and gape width decrease with increasing altitude. Among other notable changes in the frugivorous fauna across elevational gradients, we found quantitative evidence illustrating that the proportion of bird versus mammalian frugivores increases with altitude, while TMF primates decrease in diversity and density, and switch diets to include less fruit and more leaf proportionately. A paucity of studies on dispersal distance and seed shadows, the dispersal/predation balance and density-dependent mortality thwart much-needed conclusive comparisons of seed dispersal ecology between TMF and TLF, especially from understudied Asian forests. We examine the available evidence, reveal knowledge gaps and recommend research to enhance our understanding of seed dispersal ecology in tropical forests. This review demonstrates that seed dispersal is a more deterministic and important process in tropical montane forests than has been previously appreciated.
Repeat rectal chlamydia infection is common in men who have sex with men (MSM) following treatment with 1 g azithromycin. This study describes the association between organism load and repeat rectal chlamydia infection, genovar distribution, and efficacy of azithromycin in asymptomatic MSM. Stored rectal chlamydia-positive samples from MSM were analysed for organism load and genotyped to assist differentiation between reinfection and treatment failure. Included men had follow-up tests within 100 days of index infection. Lymphogranuloma venereum and proctitis diagnosed symptomatically were excluded. Factors associated with repeat infection, treatment failure and reinfection were investigated. In total, 227 MSM were included – 64 with repeat infections [28·2%, 95% confidence interval (CI) 22·4–34·5]. Repeat positivity was associated with increased pre-treatment organism load [odds ratio (OR) 1·7, 95% CI 1·4–2·2]. Of 64 repeat infections, 29 (12·8%, 95% CI 8·7–17·8) were treatment failures and 35 (15·4%, 95% CI 11·0–20·8) were reinfections, 11 (17·2%, 95% CI 8·9–28·7) of which were definite reinfections. Treatment failure and reinfection were both associated with increased load (OR 2·0, 95% CI 1·4–2·7 and 1·6, 95% CI 1·2–2·2, respectively). The most prevalent genovars were G, D and J. Treatment efficacy for 1 g azithromycin was 83·6% (95% CI 77·2–88·8). Repeat positivity was associated with high pre-treatment organism load. Randomized controlled trials are urgently needed to evaluate azithromycin's efficacy and whether extended doses can overcome rectal infections with high organism load.