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The Bonebridge is an active transcutaneous bone conduction implant recommended as a surgical option for adults and children (aged 5–18 years). Successful implantation of the Bonebridge is often restricted by an insufficient amount of temporal bone to house the transducer in the paediatric patient.
Method and results
In this unique paediatric case, bilateral Bonebridge devices were implanted simultaneously in the right sinodural angle and the left middle cranial fossa.
The simultaneous implantation of bilateral Bonebridge devices was well tolerated in this paediatric patient, with significant improvement in her hearing. The middle cranial fossa is a viable option for housing the transducer.
There is increasing evidence to support integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum exists. Using Delphi methodology, we aimed to identify and establish content validity for adult EM curricular content best suited for simulation-based training, to inform national postgraduate EM training.
A national panel of experts in EM simulation iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed. Topics scoring <2/4 were removed and remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics rated ≥ 3.5/4 were considered “core” curricular topics, while those rated 3.0-3.5 were considered “extended” curricular topics.
Forty-five experts from 13 Canadian centres participated. Two hundred eighty potential curricular topics, in 29 domains, were generated from a systematic literature review, relevant educational documents and Delphi panellists. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in eight domains, reached consensus as “core” curricular topics. Thirty-five additional topics, in 14 domains, reached consensus as “extended” curricular topics.
Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.
Zn plays an important role in maintaining the anti-oxidant status within the heart and helps to counter the acute redox stress that occurs during myocardial ischaemia and reperfusion. Individuals with low Zn levels are at greater risk of developing an acute myocardial infarction; however, the impact of this on the extent of myocardial injury is unknown. The present study aimed to compare the effects of dietary Zn depletion with in vitro removal of Zn (N,N,N′,N′-tetrakis(2-pyridinylmethyl)-1,2-ethanediamine (TPEN)) on the outcome of acute myocardial infarction and vascular function. Male Sprague–Dawley rats were fed either a Zn-adequate (35 mg Zn/kg diet) or Zn-deficient (<1 mg Zn/kg diet) diet for 2 weeks before heart isolation. Perfused hearts were subjected to a 30 min ischaemia/2 h reperfusion (I/R) protocol, during which time ventricular arrhythmias were recorded and after which infarct size was measured, along with markers of anti-oxidant status. In separate experiments, hearts were challenged with the Zn chelator TPEN (10 µm) before ischaemia onset. Both dietary and TPEN-induced Zn depletion significantly extended infarct size; dietary Zn depletion was associated with reduced total cardiac glutathione (GSH) levels, while TPEN decreased cardiac superoxide dismutase 1 levels. TPEN, but not dietary Zn depletion, also suppressed ventricular arrhythmias and depressed vascular responses to nitric oxide. These findings demonstrate that both modes of Zn depletion worsen the outcome from I/R but through different mechanisms. Dietary Zn deficiency, resulting in reduced cardiac GSH, is the most appropriate model for determining the role of endogenous Zn in I/R injury.
Anti-retroviral therapy (ART) regimes for HIV are associated with raised levels of circulating triglycerides (TGs) in western populations. However, there are limited data on the impact of ART on cardiometabolic risk in sub-Saharan African (SSA) populations.
Pooled analyses of 14 studies comprising 21 023 individuals, on whom relevant cardiometabolic risk factors (including TG), HIV and ART status were assessed between 2003 and 2014, in SSA. The association between ART and raised TG (>2.3 mmol/L) was analysed using regression models.
Among 10 615 individuals, ART was associated with a two-fold higher probability of raised TG (RR 2.05, 95% CI 1.51–2.77, I2 = 45.2%). The associations between ART and raised blood pressure, glucose, HbA1c, and other lipids were inconsistent across studies.
Evidence from this study confirms the association of ART with raised TG in SSA populations. Given the possible causal effect of raised TG on cardiovascular disease (CVD), the evidence highlights the need for prospective studies to clarify the impact of long term ART on CVD outcomes in SSA.
B. Sicardy, Observatoire de Paris and University Pierre et Marie Curie Paris, FRANCE,
M. El Moutamid, Cornell University Ithaca, New York, USA,
A. C. Quillen, University of Rochester Rochester, New York, USA,
P. M. Schenk, Lunar and Planetary Institute Houston, Texas, USA,
M. R. Showalter, SETI Institute Mountain View, California, USA,
K. Walsh, Southwest Research Institute Boulder, Colorado, USA
The sport horse industry in Great Britain is fragmented and serendipitous. However, there are many opportunities available for it to develop and grow. The research this paper is based upon was carried out in conjunction with British Breeding, to improve and develop the marketing of the British sport horse. The research was carried out through an online questionnaire (a paper version was also available) and semi-structured interviews. Both research methods contained questions aimed specifically at breeders or buyers, as well as general questions. Once the data had been collected it was analysed to discover where any trends, relationships or discrepancies existed between the groups. Recommendations were then formulated. Specifically, this paper considers the profiles of breeders and buyers of the sport horse, the reasons for breeding horses or ponies, the characteristics of horses valued by breeders and buyers and the methods of sale and purchase used. The significant difference between the horse purchase price of different categories of buyers, for example the leisure rider and professional rider, or eventers and show jumpers, are discussed. Profitability in relation to the reasons people breed horses or ponies is analysed. The definition of the sport horse is also examined. In conclusion, there is much work that needs to be completed to enable the sport horse industry in this country to be fully understood, from both the perspective of the breeder or producer and the buyer. However, there are opportunities available for the British sport horse industry to move forward.
Candida auris (CA) is an emerging multidrug-resistant pathogen associated with increased mortality. The environment may play a role, but transmission dynamics remain poorly understood. We sought to limit environmental and patient CA contamination following a sustained unsuspected exposure.
A 528-bed teaching hospital.
The index case patient and 17 collocated ward mates.
Immediately after confirmation of CA in the bloodstream and urine of a patient admitted 6 days previously, active surveillance, enhanced transmission-based precautions, environmental cleaning with peracetic acid-hydrogen peroxide and ultraviolet light, and patient relocation were undertaken. Pre-existing agreements and foundational relationships among internal multidisciplinary teams and external partners were leveraged to bolster detection and mitigation efforts and to provide genomic epidemiology.
Candida auris was isolated from 3 of 132 surface samples on days 8, 9, and 15 of ward occupancy, and from no patient samples (0 of 48). Environmental and patient isolates were genetically identical (4–8 single-nucleotide polymorphisms [SNPs]) and most closely related to the 2013 India CA-6684 strain (~200 SNPs), supporting the epidemiological hypothesis that the source of environmental contamination was the index case patient, who probably acquired the South Asian strain from another New York hospital. All isolates contained a mutation associated with azole resistance (K163R) found in the India 2105 VPCI strain but not in CA-6684. The index patient remained colonized until death. No surfaces were CA-positive 1 month later.
Compared to previous descriptions, CA dissemination was minimal. Immediate access to rapid CA diagnostics facilitates early containment strategies and outbreak investigations.
Most studies on digestion in the equine have been carried out with animals confined to stables with little or no exercise. An increased rate of digesta passage has been reported in exercised versus non exercise horses with an associated decrease in digestibility (Pagan et al., 1998). Microbial degradation makes an important contribution to diet digestibility in the equine. It is not clear however, if exercise has any effect on the composition and activity of the microbial population within hindgut which may impact on the digestion. The aim of this experiment was to assess the impact of exercise on microbial fermentation within the hindgut of the horse.
A range of endophenotypes characterise psychosis, however there has been limited work understanding if and how they are inter-related.
This multi-centre study includes 8754 participants: 2212 people with a psychotic disorder, 1487 unaffected relatives of probands, and 5055 healthy controls. We investigated cognition [digit span (N = 3127), block design (N = 5491), and the Rey Auditory Verbal Learning Test (N = 3543)], electrophysiology [P300 amplitude and latency (N = 1102)], and neuroanatomy [lateral ventricular volume (N = 1721)]. We used linear regression to assess the interrelationships between endophenotypes.
The P300 amplitude and latency were not associated (regression coef. −0.06, 95% CI −0.12 to 0.01, p = 0.060), and P300 amplitude was positively associated with block design (coef. 0.19, 95% CI 0.10–0.28, p < 0.001). There was no evidence of associations between lateral ventricular volume and the other measures (all p > 0.38). All the cognitive endophenotypes were associated with each other in the expected directions (all p < 0.001). Lastly, the relationships between pairs of endophenotypes were consistent in all three participant groups, differing for some of the cognitive pairings only in the strengths of the relationships.
The P300 amplitude and latency are independent endophenotypes; the former indexing spatial visualisation and working memory, and the latter is hypothesised to index basic processing speed. Individuals with psychotic illnesses, their unaffected relatives, and healthy controls all show similar patterns of associations between endophenotypes, endorsing the theory of a continuum of psychosis liability across the population.
Functional neurological disorders (FNDs), also known as conversion disorder, are unexplained neurological symptoms unrelated to a neurological cause. The disorder is common, yet poorly understood. The symptoms are experienced as involuntary but have similarities to voluntary processes. Here we studied intention awareness in FND.
A total of 26 FND patients and 25 healthy volunteers participated in this functional magnetic resonance study using Libet's clock.
FND is characterized by delayed awareness of the intention to move relative to the movement itself. The reporting of intention was more precise, suggesting that these findings are reliable and unrelated to non-specific attentional deficits. That these findings were more prominent with aberrant positive functional movement symptoms rather than negative symptoms may be relevant to impairments in timing for an inhibitory veto process. Attention towards intention relative to movement was associated with lower right inferior parietal cortex activity in FND, a region early in the processing of intention. During rest, aberrant functional connectivity was observed with the right inferior parietal cortex and other motor intention regions.
The results converge with observations of low inferior parietal activity comparing involuntary with voluntary movement in FND, emphasizing core deficiencies in intention. Heightened precision of this impaired intention is consistent with Bayesian theories of impaired top-down priors that might influence the sense of involuntariness. A primary impairment in voluntary motor intention at an early processing stage might explain clinical observations of slowed effortful voluntary movement, heightened self-directed attention and underlie functional movements. These findings further suggest novel therapeutic targets.
The number of South American camelids (SACs) in England and Wales is increasing and with this comes a risk of new and emerging infections. Although classified as livestock, these animals are also treated as pets and may be in regular contact with humans. This paper reviews zoonotic diseases that have been identified in SACs in England and Wales, and which pose a potential risk to human health. We also highlight the importance of surveillance continuing to capture information on infections in SACs for the protection of both public and animal health.
The free shear layer that separates from the leading edge of a round-nosed plate has been studied under conditions of low (background) and elevated (grid-generated) free stream turbulence (FST) using high-fidelity particle image velocimetry. Transition occurs after separation in each case, followed by reattachment to the flat surface of the plate downstream. A bubble of reverse flow is thereby formed. First, we find that, under elevated (7 %) FST, the time-mean bubble is almost threefold shorter due to an accelerated transition of the shear layer. Quadrant analysis of the Reynolds stresses reveals the presence of slender, highly coherent fluctuations amid the laminar part of the shear layer that are reminiscent of the boundary-layer streaks seen in bypass transition. Instability and the roll-up of vortices then follow near the crest of the shear layer. These vortices are also present under low FST and in both cases are found to make significant contributions to the production of Reynolds stress over the rear of the bubble. But their role in reattachment, whilst important, is not yet fully clear. Instantaneous flow fields from the low-FST case reveal that the bubble of reverse flow often breaks up into two or more parts, thereby complicating the overall reattachment process. We therefore suggest that the downstream end of the ‘separation isoline’ (the locus of zero absolute streamwise velocity that extends unbroken from the leading edge) be used to define the instantaneous reattachment point. A histogram of this point is found to be bimodal: the upstream peak coincides with the location of roll-up, whereas the downstream mode may suggest a ‘flapping’ motion.
A large-plot field experiment was conducted at Keiser, AR, from fall of 2010
through fall of 2013 to understand to what extent soybean in-crop herbicide
programs and postharvest fall management practices impact Palmer amaranth
population density and seed production over three growing seasons. The
effect of POST-only (glyphosate-only) or PRE followed by (fb) POST
(glyphosate or glufosinate) + residual herbicide treatments were evaluated
alone and in combination with postharvest management options of soybean
residue spreading or soil incorporation, use of cover crops, windrowing
with/without burning, and residue removal. Significant differences were
observed between fall management practices on Palmer amaranth population
density each fall. The use of cover crops and residue collection and removal
fb the incorporation of crop residues into soil during the formation of beds
were the most effective practices in reducing Palmer amaranth population. In
contrast, the effects of fall management practices on Palmer amaranth seed
production were inconsistent among years. The inclusion of a PRE herbicide
application into the herbicide program significantly reduced Palmer amaranth
population density and subsequent seed production each year when compared to
the glyphosate-only program. Additionally, the glufosinate-containing
residual program was superior to the glyphosate-containing residual program
in reducing Palmer amaranth seed production. PRE fb POST herbicides resulted
in significant decreases in the Palmer amaranth population density and seed
production compared to POST application of glyphosate alone for all fall
management practices, including the no-till practice. This study
demonstrated that crop residue management such as chaff removal from the
field, the use of cover crops, or seed incorporation during bed formation in
combination with an effective PRE plus POST residual herbicide program is
important for optimizing in-season management of Palmer amaranth and
subsequently reducing the population density, which has a profound impact on
lessening the risk for herbicide resistance and the consistency and
effectiveness of future weed management efforts.
The inner few hundred parsecs of the Milky Way, the Central Molecular Zone (CMZ), is our closest laboratory for understanding star formation in the extreme environments (hot, dense, turbulent gas) that once dominated the universe. We present an update on the first large-area survey to expose the sites of star formation across the CMZ at high-resolution in submillimeter wavelengths: the CMZoom survey with the Submillimeter Array (SMA). We identify the locations of dense cores and search for signatures of embedded star formation. CMZoom is a three-year survey in its final year and is mapping out the highest column density regions of the CMZ in dust continuum and a variety of spectral lines around 1.3 mm. CMZoom combines SMA compact and subcompact configurations with single-dish data from BGPS and the APEX telescope, achieving an angular resolution of about 4″ (0.2 pc) and good image fidelity up to large spatial scales.
Twin studies have lacked statistical power to apply advanced genetic modelling techniques to the search for cognitive endophenotypes for bipolar disorder.
To quantify the shared genetic variability between bipolar disorder and cognitive measures.
Structural equation modelling was performed on cognitive data collected from 331 twins/siblings of varying genetic relatedness, disease status and concordance for bipolar disorder.
Using a parsimonious AE model, verbal episodic and spatial working memory showed statistically significant genetic correlations with bipolar disorder (rg = |0.23|–|0.27|), which lost statistical significance after covarying for affective symptoms. Using an ACE model, IQ and visual-spatial learning showed statistically significant genetic correlations with bipolar disorder (rg = |0.51|–|1.00|), which remained significant after covarying for affective symptoms.
Verbal episodic and spatial working memory capture a modest fraction of the bipolar diathesis. IQ and visual-spatial learning may tap into genetic substrates of non-affective symptomatology in bipolar disorder.
During 1990 we surveyed the southern sky using a multi-beam receiver at frequencies of 4850 and 843 MHz. The half-power beamwidths were 4 and 25 arcmin respectively. The finished surveys cover the declination range between +10 and −90 degrees declination, essentially complete in right ascension, an area of 7.30 steradians. Preliminary analysis of the 4850 MHz data indicates that we will achieve a five sigma flux density limit of about 30 mJy. We estimate that we will find between 80 000 and 90 000 new sources above this limit. This is a revised version of the paper presented at the Regional Meeting by the first four authors; the surveys now have been completed.