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Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.
To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).
We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.
The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.
In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.
Declaration of interest
R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
Declaration of interest
Six of the 16 authors have received royalties or fees for RO DBT. R.J.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from NIHR. T.R.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd and a grant outside the submitted work from the Medical Research Council. He was codirector of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two current directors of Radically Open Ltd. H.O’M. reports personal fees from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.C.R. provides RO DBT supervision through S C Rushbrook Ltd. I.T.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M.St. reports personal fees from British Isles DBT Training, Stanton Psychological Services Ltd, and Taylor & Francis Ltd. M.Sw. reports personal fees from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis Ltd. B.W. was codirector of Radically Open Ltd between November 2014 and February 2015.
Objectives: To describe multivariate base rates (MBRs) of low scores and reliable change (decline) scores on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) in college athletes at baseline, as well as to assess MBR differences among demographic and medical history subpopulations. Methods: Data were reported on 15,909 participants (46.5% female) from the NCAA/DoD CARE Consortium. MBRs of ImPACT composite scores were derived using published CARE normative data and reliability metrics. MBRs of sex-corrected low scores were reported at <25th percentile (Low Average), <10th percentile (Borderline), and ≤2nd percentile (Impaired). MBRs of reliable decline scores were reported at the 75%, 90%, 95%, and 99% confidence intervals. We analyzed subgroups by sex, race, attention-deficit/hyperactivity disorder and/or learning disability (ADHD/LD), anxiety/depression, and concussion history using chi-square analyses. Results: Base rates of low scores and reliable decline scores on individual composites approximated the normative distribution. Athletes obtained ≥1 low score with frequencies of 63.4% (Low Average), 32.0% (Borderline), and 9.1% (Impaired). Athletes obtained ≥1 reliable decline score with frequencies of 66.8%, 32.2%, 18%, and 3.8%, respectively. Comparatively few athletes had low scores or reliable decline on ≥2 composite scores. Black/African American athletes and athletes with ADHD/LD had higher rates of low scores, while greater concussion history was associated with lower MBRs (p < .01). MBRs of reliable decline were not associated with demographic or medical factors. Conclusions: Clinical interpretation of low scores and reliable decline on ImPACT depends on the strictness of the low score cutoff, the reliable change criterion, and the number of scores exceeding these cutoffs. Race and ADHD influence the frequency of low scores at all cutoffs cross-sectionally.
The patterns and drivers of late Quaternary vegetation dynamics in the southeastern United States are poorly understood due to low site density, problematic chronologies, and a paucity of independent paleoclimate proxy records. We present a well-dated (15 accelerator mass spectrometry 14C dates) 30,000-yr record from White Pond, South Carolina that consists of high-resolution analyses of fossil pollen, macroscopic charcoal, and Sporormiella spores, and an independent paleotemperature reconstruction based on branched glycerol dialkyl tetraethers. Between 30,000 and 20,000 cal yr BP, open Pinus-Picea forest grew under cold and dry conditions; elevated Quercus before 26,000 cal yr BP, however, suggest warmer conditions in the Southeast before the last glacial maximum, possibly corresponding to regionally warmer conditions associated with Heinrich event H2. Warming between 19,700 and 10,400 cal yr BP was accompanied by a transition from conifer-dominated to mesic hardwood forest. Sporormiella spores were not detected and charcoal was low during the late glacial period, suggesting megaherbivore grazers and fire were not locally important agents of vegetation change. Pinus returned to dominance during the Holocene, with step-like increases in Pinus at 10,400 and 6400 cal yr BP, while charcoal abundance increased tenfold, likely due to increased biomass burning associated with warmer conditions. Low-intensity surface fires increased after 1200 cal yr BP, possibly related to the establishment of the Mississippian culture in the Southeast.
A global coupled atmosphere–ocean model is used to examine the hydrologic cycle of the Arctic Ocean. The model has a horizontal resolution of 4° × 5°, nine vertical layers in the atmosphere and 13 in the ocean. River discharge into the Arctic Ocean is included by allowing runoff from each continental grid box to flow downstream according to a specified direction file and a speed that depends on topography. A 74 year control simulation of the present climate is used to examine variability of the hydrologic cycle, including precipitation, sea ice, glacial ice and river discharge. A 74 year transient simulation in which atmospheric CO2 increases each year at a compound rate оf 1% is then used to examine potential changes in the hydrologic cycle. Among these changes are a 4°C increase in mean annual surface air temperature in the Arctic Ocean, a decrease in ice cover which begins after 35 years, and increases in river discharge and cloud cover. There is little change in the net difference between precipitation and evaporation. Also in the transient simulation, glacial ice on Greenland decreases relative to the control.
A global coupled atmosphere-ocean-ice model is used to examine the
interdependence among several components of the hydrologic cycle in the
Arctic Ocean, including river discharge, sea-ice cover, and the flow of sea
ice through Fram Strait. Since the ocean model has a free surface,
fresh-water inflow from rivers is added directly to the ocean. The timing of
the peak spring river flow depends on snowmelt runoff and its subsequent
routing through the river system. Thermodynamic sea ice is included, and a
new sea-iee advection scheme is described. The model’s river discharge
affects salinity at the mouth of large rivers. The effect of the river
discharge on sea-ice cover is not clear, either locally or at the basin
scale. There is significant inter-annual variability of ice flow through
Fram Strait, but the model’s flow is about half of that observed. The
anomalous ice flow through Fram Strait is most highly correlated with the
meridional wind stress. Potential implications for the “great salinity”
anomaly are discussed.
We have undertaken an adaptive optics imaging survey of extra-solar planetary systems and stars showing interesting radial velocity trends from high precision radial velocity searches. Adaptive Optics increases the resolution and dynamic range of an image, substantially improving the detectability of faint close companions. This survey is sensitive to objects less luminous than the bottom of the main sequence at separations as close as 1″. We have detected stellar companions to the planet bearing stars HD 114762 and Tau Boo. We have also detected a companion to the non-planet bearing star 16 Cyg A.
The addition of a CdMgTe (CMT) layer at the back of a CdTe solar cell should improve its performance by reflecting both photoelectrons and forward-current electrons away from the rear surface. Higher collection of photoelectrons will increase the cell’s current, and reduction of forward current will increase its voltage. To achieve electron reflection, conformal CMT layers were deposited at the back of CdTe cells, and a variety of measurements including performance curves, transmission electron microscopy, x-ray photoelectron spectroscopy, and energy-dispersive x-ray spectroscopy were performed. Oxidation of magnesium in the CMT layer was addressed by adding a CdTe capping layer. MgCl2 passivation was substituted for CdCl2 in some cases, but little difference was seen.
The number of pediatric antimicrobial stewardship programs (ASPs) is increasing and program evaluation is a key component to improve efficiency and enhance stewardship strategies.
To determine the antimicrobials and diagnoses most strongly associated with a recommendation provided by a well-established pediatric ASP.
DESIGN AND SETTING
Retrospective cohort study from March 3, 2008, to March 2, 2013, of all ASP reviews performed at a free-standing pediatric hospital.
ASP recommendations were classified as follows: stop therapy, modify therapy, optimize therapy, or consult infectious diseases. A multinomial distribution model to determine the probability of each ASP recommendation category was performed on the basis of the specific antimicrobial agent or disease category. A logistic model was used to determine the odds of recommendation disagreement by the prescribing clinician.
The ASP made 2,317 recommendations: stop therapy (45%), modify therapy (26%), optimize therapy (19%), or consult infectious diseases (10%). Third-generation cephalosporins (0.20) were the antimicrobials with the highest predictive probability of an ASP recommendation whereas linezolid (0.05) had the lowest probability. Community-acquired pneumonia (0.26) was the diagnosis with the highest predictive probability of an ASP recommendation whereas fever/neutropenia (0.04) had the lowest probability. Disagreement with ASP recommendations by the prescribing clinician occurred 22% of the time, most commonly involving community-acquired pneumonia and ear/nose/throat infections.
Evaluation of our pediatric ASP identified specific clinical diagnoses and antimicrobials associated with an increased likelihood of an ASP recommendation. Focused interventions targeting these high-yield areas may result in increased program efficiency and efficacy.
The traditional CdCl2 passivation of CdTe is expanded by adding other chlorides such as MgCl2, NaCl, and MnCl2 into the process through a two-step passivation procedure that combines closed space sublimation step with a vapor process. This allows the possibility of forming a highly doped field at the back of the device that could act as an electron reflector that could boost device performance by directing electrons back into the absorber layer and increasing the voltage while limiting recombination at the back of the device. The effects the two-step passivation process on device performance are characterized by current-voltage measurements, and by electroluminescence and laser-beam induced current images to show the degree of device uniformity. Additionally, capacitance voltage measurements are used to study doping density, depletion width, and possible formation of a field at the back of the device.
Two detailed sections through 4 km of distal alluvium of the Upper Devonian Old Red Sandstone in the Munster Basin, southern Ireland, display a limited number of lithofacies. There is little ordering of these lithofacies on a small scale but changes in the proportions of lithofacies through time define a sequence of stages of basin evolution. The depositional environments changed progressively from sheetflood dominant, via mobile ephemeral channels and floodplains to a more fixed channel–overbank system and eventually to a coastal plain. On the basis of the sedimentary record a progressive reduction in subsidence rate with time is deduced as the main control on the evolution of the basin fill. This deduction is consistent with predictions from previously applied extensional basin models, but is insufficiently refined at present to distinguish between the different models.
The properties of water near surfaces are known to differ from those of the bulk. For instance, in 140 A diameter silica pores the density has been found to be 3% lower than that of the bulk while the heat capacity is 25% greater than that the bulk. Etzler  has proposed a statistical thermodynamic model for vicinal water. This model has been able to correlate a number of thermodynamic properties of water in silica pores. Furthermore, some of the microscopic implications of the model have been found to be consistent with molecular dynamics simulations. Here we discuss the results of a statistical geometric analysis of a molecular dynamics simulation which, as first suggested by Roentgen (1892), indicates that water indeed exists in “bulky” and “dense” states. Furthermore, recent results concerning the temperature dependence of the heat capacity of water in silica pores is discussed.
5-Amino-3-nitro-lH-1,2,4-triazole (ANTA) is a molecule with high stability. Aside from being an insensitive high explosive (IHE), it is also used as a synthon for other potential new IHEs. The crystal structure of ANTA was resolved by X-ray crystallography. However, when ANTA was recrystallized from 2-butanone, crystals with molecular packing characterized by extended planar sheets were obtained (ß-ANTA). The crystal density of ß-ANTA is 1.73 g/cm3, which is less dense than α-ANTA (p = 1.82g/cm3).
The high-nitrogen molecule, 5,5'-dinitro-3,3'-azo-1,2,4-triazole (DNAT) was calculated to have a high density and a positive heat of formation (AHf). In an attempt to prepare DNAT, we have studied the oxidation of ANTA with different oxidizers. It was found that DNAT is the reaction product when the potassium salt of ANTA was oxidized with potassium permanganate. However, when ANTA was oxidized with ammonium persulfate in aqueous medium, one of the reaction products obtained was the azoxy moleclue of DNAT (DNAzT). We are unable to determine the crystal densities of either DNAT and DNAzT because the crystals obtained were solvated with the crystallization solvents.
Relationships between the X-ray and radio behavior of black hole X-ray binaries during outbursts have established a fundamental coupling between the accretion disks and radio jets in these systems. I begin by reviewing the prevailing paradigm for this disk-jet coupling, also highlighting what we know about similarities and differences with neutron star and white dwarf binaries. Until recently, this paradigm had not been directly tested with dedicated high-angular resolution radio imaging over entire outbursts. Moreover, such high-resolution monitoring campaigns had not previously targetted outbursts in which the compact object was either a neutron star or a white dwarf. To address this issue, we have embarked on the Jet Acceleration and Collimation Probe Of Transient X-Ray Binaries (JACPOT XRB) project, which aims to use high angular resolution observations to compare disk-jet coupling across the stellar mass scale, with the goal of probing the importance of the depth of the gravitational potential well, the stellar surface and the stellar magnetic field, on jet formation. Our team has recently concluded its first monitoring series, including (E)VLA, VLBA, X-ray, optical, and near-infrared observations of entire outbursts of the black hole candidate H 1743-322, the neutron star system Aquila X-1, and the white dwarf system SS Cyg. Here I present preliminary results from this work, largely confirming the current paradigm, but highlighting some intriguing new behavior, and suggesting a possible difference in the jet formation process between neutron star and black hole systems.
In this communication, we study the statistical properties of the light intensity in direct and coronagraphic images, in the context of ground-based Extreme Adaptive Optics observations. The same approach can also be used for space observations with different scales. We show that a coronagraph only affects the perfect part of the wave and leaves the uncorrected part of the wavefront almost unaffected. This statistical model can explain the ‘speckle pinning’ effect (presence of speckles at the position of the diffraction rings), as an amplification of the speckle noise. This statistical approach can be verified on real adaptive optics data.
Repeated neuropsychological assessments are common with older adults,
and the determination of clinically significant change across time is
an important issue. Regression-based prediction formulas have been
utilized with other patient and healthy control samples to predict
follow-up test performance based on initial performance and demographic
variables. Comparisons between predicted and observed follow-up
performances can assist clinicians in determining the significance of
change in the individual patient. In the current study, multiple
regression-based prediction equations for the 5 Indexes and Total Score
of the RBANS were developed for a sample of 223 community dwelling
older adults. These algorithms were then validated on a separate
elderly sample (N = 222). Minimal differences were present
between observed and predicted follow-up scores in the validation
sample, suggesting that the prediction formulas are clinically useful
for practitioners who assess older adults. A case example is presented
that illustrates how the algorithms can be used clinically.
(JINS, 2004, 10, 828–834.)