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Sepsis, a common, time-sensitive condition, is sometimes not identified at emergency department (ED) triage. The use of early warning scores has been shown to improve sepsis-related screening in other settings.
Our objective was to elucidate nurse and physician perceptions with the Hamilton Early Warning Score (HEWS) in combination with the Canadian Triage Acuity Scale.
Semi-structured interviews were conducted with nurses, resident physicians and attending physicians to explore perceived feasibility, utility, comfort, barriers, successes, opportunities and accuracy. A constructivist grounded theory approach was used. Transcripts were coded into thematic coding trees.
The twelve participants did not value the HEWS in the ED because they felt it was not helpful in identifying critically ill patients. We identified five themes; knowledge of sepsis and HEWS, utility of HEWS in emergency triage, utility of HEWS at the bedside, utility in communicating acuity and deterioration, and feasibility and accuracy of data collection. We also found 9 barriers and 7 enablers to the use of early warning score in the ED.
In our emergency departments, we identified potential barriers to implementation of an early warning score. A pre-existing expertise and lexicon related to critically ill patients lessens the perceived utility of an EWS in the ED. Understanding these cultural barriers needs to be addressed through change theory and implementation science.
Children reared in impoverished environments are at risk for enduring psychological and physical health problems. Mechanisms by which poverty affects development, however, remain unclear. To explore one potential mechanism of poverty's impact on social–emotional and cognitive development, an experimental examination of a rodent model of scarcity-adversity was conducted and compared to results from a longitudinal study of human infants and families followed from birth (N = 1,292) who faced high levels of poverty-related scarcity-adversity. Cross-species results supported the hypothesis that altered caregiving is one pathway by which poverty adversely impacts development. Rodent mothers assigned to the scarcity-adversity condition exhibited decreased sensitive parenting and increased negative parenting relative to mothers assigned to the control condition. Furthermore, scarcity-adversity reared pups exhibited decreased developmental competence as indicated by disrupted nipple attachment, distress vocalization when in physical contact with an anesthetized mother, and reduced preference for maternal odor with corresponding changes in brain activation. Human results indicated that scarcity-adversity was inversely correlated with sensitive parenting and positively correlated with negative parenting, and that parenting fully mediated the association of poverty-related risk with infant indicators of developmental competence. Findings are discussed from the perspective of the usefulness of bidirectional–translational research to inform interventions for at-risk families.
Previous work has shown that amygdala responsiveness to fearful expressions is inversely related to level of callous-unemotional (CU) traits (i.e. reduced guilt and empathy) in youth with conduct problems. However, some research has suggested that the relationship between pathophysiology and CU traits may be different in those youth with significant prior trauma exposure.
In experiment 1, 72 youth with varying levels of disruptive behavior and trauma exposure performed a gender discrimination task while viewing morphed fear expressions (0, 50, 100, 150 fear) and Blood Oxygenation Level Dependent responses were recorded. In experiment 2, 66 of these youth performed the Social Goals Task, which measures self-reports of the importance of specific social goals to the participant in provoking social situations.
In experiment 1, a significant CU traits-by-trauma exposure interaction was observed within right amygdala; fear intensity-modulated amygdala responses negatively predicted CU traits for those youth with low levels of trauma but positively predicted CU traits for those with high levels of trauma. In experiment 2, a bootstrapped model revealed that the indirect effect of fear intensity amygdala response on social goal importance through CU traits is moderated by prior trauma exposure.
This study, while exploratory, indicates that the pathophysiology associated with CU traits differs in youth as a function of prior trauma exposure. These data suggest that prior trauma exposure should be considered when evaluating potential interventions for youth with high CU traits.
Alterations in reinforcement-based decision making may be associated with increased psychiatric vulnerability in children who have experienced maltreatment. A probabilistic passive avoidance task and a model-based functional magnetic resonance imaging analytic approach were implemented to assess the neurocomputational components underlying decision making: (a) reinforcement expectancies (the representation of the outcomes associated with a stimulus) and (b) prediction error signaling (the ability to detect the differences between expected and actual outcomes). There were three main findings. First, the maltreated group (n = 18; mean age = 13), relative to nonmaltreated peers (n = 19; mean age = 13), showed decreased activity during expected value processing in a widespread network commonly associated with reinforcement expectancies representation, including the striatum (especially the caudate), the orbitofrontal cortex, and medial temporal structures including the hippocampus and insula. Second, consistent with previously reported hyperresponsiveness to negative cues in the context of childhood abuse, the maltreated group showed increased prediction error signaling in the middle cingulate gyrus, somatosensory cortex, superior temporal gyrus, and thalamus. Third, the maltreated group showed increased activity in frontodorsal regions and in the putamen during expected value representation. These findings suggest that early adverse environments disrupt the development of decision-making processes, which in turn may compromise psychosocial functioning in ways that increase latent vulnerability to psychiatric disorder.
The properties of ultraviolet interstellar extinction in and near the core of the 30 Doradus Nebula are studied. The pair method is employed using nine reddened stars from within 5′ (80pc) of the core and nine unreddened stars from a variety of locations in the large Magellanic Cloud. All of the 30 Doradus stars examined appear to be reddened by E(B-V) ⋍ 0.12 with an extinction law similar in wavelength dependence to those derived for the LMC by Koornneef and Code (1981) and Nandy et al. (1981). Several of the stars, including R136a, R145 and R147, are found to be additionally reddened by E(B-V) ⋍ 0.18 with an extinction law qualitatively similar in wavelength dependence to the law found in the Orion region. A two-component model, featuring a layer of “LMC foreground dust” which affects all of the stars and a deeper layer of “nebular dust” which affects some of the stars, provides the simplest explanation of the extinction properties. The 2200 Å extinction bump is present in both curves. The wavelength positions of the bump and the bump profiles, when normalized to a linear “background extinction”, are indistinguishable from the average Galactic bump. The strengths of the bumps, relative to E(B-V), are 20–30% weaker than for the Milky Way Curve.
This paper illustrates differences in estimated returns to public agricultural research investments for the U.S. and the Northeast when value-added (VA) as opposed to gross production (GP) functions are estimated. Commodity groups considered are dairy, poultry, other livestock, and cash grains. Sizable differences are evident in returns estimated with VA as opposed to GP functions, with the VA estimates generally being larger. Cash grains research yields the largest returns at the margin. Dairy research is more productive in the Northeast than the rest of the country.
A four-man party representing the Arctic Institute of North America and the Department of Geology, Dartmouth College, went to the Ward Hunt Ice Shelf in 1960 to obtain ice cores for subsequent laboratory analysis. The overall objective of the project was to study the structural and stratigraphic history of the shelf and its relationship to the environment through laboratory analysis of the cores, using stratigraphic. petrologic, chemical, and physical methods.
The four cores obtained were logged, packed, and shipped to Dartmouth College for detailed study. The stratigraphy and structure of the ice were studied under natural and plane polarized light conditions. The results of this initial work showed that the cores were composed of four ice types: glacier ice, lake ice, sea ice, and transition ice. Chlorinity, sulfate, and density profiles complemented megascopic studies and were most useful criteria for plotting stratigraphie changes in ice type.
Results of the investigations thus far have yielded new information about the gross structure and stratigraphy of the ice shelf and re-entrant. They have also shown that the physical and chemical techniques employed will be useful in future ice-core analysis.
We observed the Planetary Nebula NGC 6720 with the Gemini Telescope and the Gemini Multi-Object Spectrographs. We obtained spatial maps of 36 emission-lines in the wavelength range between 3600 Å and 9400 Å. We derived maps of c(Hβ), electronic densities, electronic temperatures, ionic and elemental abundances, and Ionization Correction Factors (ICFs) in the source and investigated the mass-loss history of the progenitor. The elemental abundance results indicate the need for ICFs based on three-dimensional photoionization models.
The Southern Hemisphere VLBI Experiment (SHEVE) program is aimed at producing high-resolution images of southern radio sources. The radio telescopes of the present SHEVE array are described below and some recent results presented.
Here, we report the feasibility and long-term efficacy of a granulomatous slack skin disease (GSSD) treatment with combined high-energy photon and proton beams.
Patient and methods
A GSSD patient with abdominal disease volume 25×15×2–4 cm deep was recommended for treatment at this institution. In addition to photons and electrons, high-energy protons delivered with advanced planning techniques and patient positioning were used. The patient was irradiated to a total dose of 40 Gy by using 20 Gy matched photon and electrons followed by 20 Gy equivalent protons delivered by using innovative range compensation and patient positioning.
The test patient tolerated the treatment well and is now a 10-year survivor of the disease.
Treatment of GSSD with protons is feasible. The range and narrow penumbra properties of the proton beam provided an ideal capability to match fields accurately to cover large volumes while also sparing underlying normal tissues.
Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses.
To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months.
The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis.
Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months.
Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.
Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study.
Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as “important” or “very important.”
Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/ providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n 5 10), strengths/opportunities (n 5 24), and recommendations (n 5 19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda.
Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.
This study forms the first phase in the development of the Canadian National EMS Research Agenda. The purpose was to understand the current state of emergency medical services (EMS) research through the barriers and opportunities perceived by key stakeholders in the Canadian system and to identify the recommendations this group had for moving forward.
This qualitative study was conducted in the spring of 2011 using one-on-one semistructured telephone interviews. Purposeful sampling was used to recruit a cross section of EMS research stakeholders, representing a breadth of geographic regions and roles. Data were collected until thematic saturation was reached. A constant comparative approach was used to develop a basic coding framework and identify emerging themes.
Twenty stakeholders were invited to participate, and saturation was reached after 13 interviews. Thematic saturation was used to ensure that the findings were grounded in the data. Four major themes were identified: 1) the need for additional research education within EMS; 2) the importance of creating an infrastructure to support pan-Canadian research collaboration; 3) addressing the complexities of involving EMS providers in research; and 4) considerations for a national research agenda.
This hypothesis-generating study reveals key areas regarding EMS research in Canada and through the guidance it provides is a first step in the development of a comprehensive national research agenda. Our intention is to collate the identified themes with the results of a larger roundtable discussion and Delphi survey and, in doing so, guide development of a Canadian national EMS research agenda.