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Severe longitudinally extensive transverse myelitis (LETM) can cause quadriplegia, marked sensory dysfunction, and respiratory failure. Some patients are unresponsive to conventional immune therapy. We report two cases of severe immune-mediated LETM requiring intensive care admission that failed to respond to high-dose corticosteroids, plasma exchange, intravenous immunoglobulin, and rituximab. Disease cessation and significant recovery was achieved after cyclophosphamide induction. In patients with severe acute immune-mediated LETM who fail to respond to corticosteroids and plasma exchange, cyclophosphamide induction should be considered. This agent and regimen provides a robust immunosuppressive response and can be induced rapidly. Cyclophosphamide effects and supportive evidence are discussed.
Oregon's Fort Rock Cave is iconic in respect to both the archaeology of the northern Great Basin and the history of debate about when the Great Basin was colonized. In 1938, Luther Cressman recovered dozens of sagebrush bark sandals from beneath Mt. Mazama ash that were later radiocarbon dated to between 10,500 and 9350 cal B.P. In 1970, Stephen Bedwell reported finding lithic tools associated with a date of more than 15,000 cal B.P., a date dismissed as unreasonably old by most researchers. Now, with evidence of a nearly 15,000-year-old occupation at the nearby Paisley Five Mile Point Caves, we returned to Fort Rock Cave to evaluate the validity of Bedwell's claim, assess the stratigraphic integrity of remaining deposits, and determine the potential for future work at the site. Here, we report the results of additional fieldwork at Fort Rock Cave undertaken in 2015 and 2016, which supports the early Holocene occupation, but does not confirm a pre–10,500 cal B.P. human presence.
To examine: (1) gender-specific determinants of help-seeking for mental health, including health professional consultation and the use of non-clinical support services and self-management strategies (SS/SM) and; (2) gender differences among individuals with unmet perceived need for care.
Analyses focused on 689 males and 1075 females aged 16–85 years who met ICD-10 criteria for a past-year affective, anxiety or substance use disorder in an Australian community-representative survey. Two classifications of help-seeking for mental health in the previous year were created: (1) no health professional consultation or SS/SM, or health professional consultation, or SS/SM only, and; (2) no general practitioner (GP) or mental health professional consultation, or GP only consultation, or mental health professional consultation. Between- and within-gender help-seeking patterns were explored using multinomial logistic regression models. Characteristics of males and females with unmet perceived need for care were compared using chi-square tests.
Males with mental or substance use disorders had relatively lower odds than females of any health professional consultation (adjusted odds ratio [AOR] = 0.46), use of SS/SM only (AOR = 0.59), and GP only consultation (AOR = 0.29). Notably, males with severe disorders had substantially lower odds than females of any health professional consultation (AOR = 0.29) and GP only consultation (AOR = 0.14). Most correlates of help-seeking were need-related. Many applied to both genders (e.g., severity, disability, psychiatric comorbidity), although some were male-specific (e.g., past-year reaction to a traumatic event) or female-specific (e.g., past-year affective disorder). Certain enabling and predisposing factors increased the probability of health professional consultation for both genders (age 30+ years) or for males (unmarried, single parenthood, reliance on government pension). Males with unmet perceived need for care were more likely to have experienced a substance use disorder and to want medicine or tablets or social intervention, whereas their females peers were more likely to have experienced an anxiety disorder and to want counselling or talking therapy. For both genders, attitudinal/knowledge barriers to receiving the types of help wanted (e.g., not knowing where to get help) were more commonly reported than structural barriers (e.g., cost).
Findings suggest a need to address barriers to help-seeking in males with severe disorders, and promote GP consultation. Exploring gender-specific attitudinal/knowledge barriers to receiving help, and the types of help wanted, may assist in designing interventions to increase consultation. Mental health promotion/education efforts could incorporate information about the content and benefits of evidence-based treatments and encourage males to participate in other potentially beneficial actions (e.g., physical activity).
We used the winter of 2009–2010, which had minimal influenza circulation due to the earlier 2009 influenza A(H1N1) pandemic, to test the accuracy of ecological trend methods used to estimate influenza-related deaths and hospitalizations. We aggregated weekly counts of person-time, all-cause deaths, and hospitalizations for pneumonia/influenza and respiratory/circulatory conditions from seven healthcare systems. We predicted the incidence of the outcomes during the winter of 2009–2010 using three different methods: a cyclic (Serfling) regression model, a cyclic regression model with viral circulation data (virological regression), and an autoregressive, integrated moving average model with viral circulation data (ARIMAX). We compared predicted non-influenza incidence with actual winter incidence. All three models generally displayed high accuracy, with prediction errors for death ranging from −5% to −2%. For hospitalizations, errors ranged from −10% to −2% for pneumonia/influenza and from −3% to 0% for respiratory/circulatory. The Serfling and virological models consistently outperformed the ARIMAX model. The three methods tested could predict incidence of non-influenza deaths and hospitalizations during a winter with negligible influenza circulation. However, meaningful mis-estimation of the burden of influenza can still result with outcomes for which the contribution of influenza is low, such as all-cause mortality.
Despite their high prevalence, the global burden of anxiety disorders has never been calculated comprehensively. The new Global Burden of Disease (GBD) study has estimated burden due to morbidity and mortality caused by any anxiety disorder.
Prevalence was estimated using Bayesian meta-regression informed by data identified in a systematic review. Years of life lived with disability (YLDs) were calculated by multiplying prevalent cases by an average disability weight based on severity proportions (mild, moderate and severe). Disability-adjusted life years (DALYs) were then calculated and age standardized using global standard population figures. Estimates were also made for additional suicide mortality attributable to anxiety disorders. Findings are presented for YLDs, DALYs and attributable burden due to suicide for 21 world regions in 1990 and 2010.
Anxiety disorders were the sixth leading cause of disability, in terms of YLDs, in both high-income (HI) and low- and middle-income (LMI) countries. Globally, anxiety disorders accounted for 390 DALYs per 100 000 persons [95% uncertainty interval (UI) 191–371 DALYs per 100 000] in 2010, with no discernible change observed over time. Females accounted for about 65% of the DALYs caused by anxiety disorders, with the highest burden in both males and females experienced by those aged between 15 and 34 years. Although there was regional variation in prevalence, the overlap between uncertainty estimates means that substantive differences in burden between populations could not be identified.
Anxiety disorders are chronic, disabling conditions that are distributed across the globe. Future estimates of burden could be further improved by obtaining more representative data on severity state proportions.
We describe trends in incidence rates of methicillin-resistant Staphylococcus aureus (MRSA) in HIV-infected and HIV-uninfected patients enrolled in a large northern California Health Plan, and the ratio of MRSA to methicillin-susceptible S. aureus (MSSA) case counts. Between 1995 and 2010, 1549 MRSA infections were diagnosed in 14060 HIV-infected patients (11·0%) compared to 89546 MRSA infections in 6597396 HIV-uninfected patients (1·4%) (P = 0·00). A steady rise in MRSA infection rates began in 1995 in HIV-uninfected patients, peaking at 396·5 infections/100000 person-years in 2007. A more rapid rise in MRSA infection rates occurred in the HIV-infected group after 2000, peaking at 3592·8 infections/100000 in 2005. A declining trend in MRSA rates may have begun in 2008–2009. Comparing the ratio of MRSA to MSSA case counts, we observed that HIV-infected patients shouldered a greater burden of MRSA infection during most years of study follow-up compared to HIV-uninfected patients.
Few studies have examined spontaneous remission from major depression. This study investigated the proportion of prevalent cases of untreated major depression that will remit without treatment in a year, and whether remission rates vary by disorder severity.
Wait-list controlled trials and observational cohort studies published up to 2010 with data describing remission from untreated depression at ⩽2-year follow-up were identified. Remission was defined as rescinded diagnoses or below threshold scores on standardized symptom measures. Nineteen studies were included in a regression model predicting the probability of 12-month remission from untreated depression, using logit transformed remission proportion as the dependent variable. Covariates included age, gender, study type and diagnostic measure.
Wait-listed compared to primary-care samples, studies with longer follow-up duration and older adult compared to adult samples were associated with lower probability of remission. Child and adolescent samples were associated with higher probability of remission. Based on adult samples recruited from primary-care settings, the model estimated that 23% of prevalent cases of untreated depression will remit within 3 months, 32% within 6 months and 53% within 12 months.
It is undesirable to expect 100% treatment coverage for depression, given many will remit before access to services is feasible. Data were drawn from consenting wait-list and primary-care samples, which potentially over-represented mild-to-moderate cases of depression. Considering reported rates of spontaneous remission, a short untreated period seems defensible for this subpopulation, where judged appropriate by the clinician. Conclusions may not apply to individuals with more severe depression.
The literature describing the global prevalence of anxiety disorders is highly variable. A systematic review and meta-regression were undertaken to estimate the prevalence of anxiety disorders and to identify factors that may influence these estimates. The findings will inform the new Global Burden of Disease study.
A systematic review identified prevalence studies of anxiety disorders published between 1980 and 2009. Electronic databases, reference lists, review articles and monographs were searched and experts then contacted to identify missing studies. Substantive and methodological factors associated with inter-study variability were identified through meta-regression analyses and the global prevalence of anxiety disorders was calculated adjusting for study methodology.
The prevalence of anxiety disorders was obtained from 87 studies across 44 countries. Estimates of current prevalence ranged between 0.9% and 28.3% and past-year prevalence between 2.4% and 29.8%. Substantive factors including gender, age, culture, conflict and economic status, and urbanicity accounted for the greatest proportion of variability. Methodological factors in the final multivariate model (prevalence period, number of disorders and diagnostic instrument) explained an additional 13% of variance between studies. The global current prevalence of anxiety disorders adjusted for methodological differences was 7.3% (4.8–10.9%) and ranged from 5.3% (3.5–8.1%) in African cultures to 10.4% (7.0–15.5%) in Euro/Anglo cultures.
Anxiety disorders are common and the substantive and methodological factors identified here explain much of the variability in prevalence estimates. Specific attention should be paid to cultural differences in responses to survey instruments for anxiety disorders.
We describe an efficient algorithm for the inversion of covariance matrices that arise in the context of phylogenetic tree construction. Phylogenetic trees describe the evolutionary relationships between species, and their construction is computationally demanding. Many approaches involve the symmetric matrix of evolutionary distances between species. Regarding these distances as random variables, the corresponding set of variances and covariances form a rank-4 tensor, and the inner-product defined by its inverse can be used to assign statistical scores to candidate trees. We describe a natural set of assumptions for the phylogenetic tree under construction, and show how under these assumptions the covariance tensor for a tree with n leaves can be inverted in O(n2) operations. In addition to presenting the inversion algorithm, we hope this article will open algebraic and computational problems from the field of phylogeny to a wider audience.
A detailed field and microstructural investigation of mineral fabrics in the late-Caledonian Galway Granite Batholith (∼400 Ma) provides insights into the relationship between emplacement-related deformation and crystallization state. These relationships are used to infer the regional instantaneous strain pattern at the time of intrusion. A Marginal Deformation Zone occurs in the granite along part of its northern sector, where planar fabrics are contact-parallel and dip steeply to the north. Within the Marginal Deformation Zone, the granite has similar patterns of pre- and post-RCMP (Rheologically Critical Melt Percentage) fabrics on either side of the NNE-trending Shannawona Fault Zone, which separates the Western and Central blocks of the batholith. Oblate pre-RCMP fabrics, which intensify towards the contact, are overprinted in a down-temperature continuum of deformation by co-axial post-RCMP fabrics that also become more intense towards the contact. At the southern edge of the Marginal Deformation Zone, deformation ceased before the granite reached its RCMP whereas, close to the contact, deformation ceased at ∼500°C. Within the Central Block, oblate fabrics also developed parallel with internal granite facies boundaries. Throughout the batholith, the fabrics formed by co-axial deformation as a result of lateral expansion operating in successive magma batches at the emplacement level. These intrusion-related fabrics are consistent with other evidence that indicates the Galway Granite was emplaced into a transtensional setting at the end of the Caledonian Orogeny.
The aim of this project was to examine the relationships between driver behaviour and driving events during a journey and the behavioural responses of sheep to these events. Driving style can have a major influence on the welfare of the animals by affecting the risk of injury and by disturbing the ability of the sheep to rest. Two drivers each drove groups of 10 sheep in a 5·5-tonne, single-deck, non-articulated livestock vehicle on five 7-h road journeys consisting of minor roads, main single carriageways and a motorway. The driver, the driver’s view through the windscreen, the speedometer and the sheep were video recorded. Differences in driving style were identified as differences in vehicle speed, rapid braking and the number of corners taken with high cornering g-force. Differences in driving style had a slight effect on the frequency of losses of balance by the sheep and a more significant effect on the degree of disturbance to the sheep and on their ability to rest during the journey. Losses of balance were common, but falls were rare. About 80% of the losses of balance could have been caused by driving events, such as acceleration, braking, stopping, cornering, gear changes and uneven road surfaces. Only about 22% of driving events were followed by a loss of balance. It is likely that driving events were also responsible for many interruptions to both lying behaviour and rumination. Clear benefits of motorway driving compared with single carriageway driving were fewer losses of balance, more lying down, more rumination and fewer disturbances amongst the sheep. This study provides evidence that would be useful for driver training and education to promote careful driving as a means of ensuring the welfare of animals in-transit. The quality of the journey experienced by sheep during transport is dependent upon a number of factors that can be influenced by the driver of the vehicle.
The present study examined whether replacing fat with inulin or lupin-kernel fibre influenced palatability, perceptions of satiety, and food intake in thirty-three healthy men (mean age 52 years, BMI 27·4kg/m2), using a within-subject design. On separate occasions, after fasting overnight, the participants consumed a breakfast consisting primarily of either a full-fat sausage patty (FFP) or a reduced-fat patty containing inulin (INP) or lupin-kernel fibre (LKP). Breakfast variants were alike in mass, protein and carbohydrate content; however the INP and LKP breakfasts were 36 and 37% lower in fat and 15 and 17% lower in energy density respectively compared with the FFP breakfast. The participants rated their satiety before breakfast then evaluated patty acceptability. Satiety was rated immediately after consuming the breakfast, then over the subsequent 4·5h whilst fasting. Food consumed until the end of the following day was recorded. All patties were rated above ‘neither acceptable or unacceptable’, however the INP rated lower for general acceptability (P=0·039) and the LKP lower for flavour (P=0·023) than the FFP. The LKP breakfast rated more satiating than the INP (P=0·010) and FFP (P=0·016) breakfasts. Total fat intake was 18g lower on the day of the INP (P=0·035) and 26g lower on the day of the LKP breakfast (P=0·013) than the FFP breakfast day. Energy intake was lower (1521kJ) only on the day of the INP breakfast (P=0·039). Both inulin and lupin-kernel fibre appear to have potential as fat replacers in meat products and for reducing fat and energy intake in men.
Background. We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.
Method. Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.
Results. Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0·78, 95% CI 0·53 to 1·14, P=0·20).
Conclusion. Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.
This preliminary work reports the preparation of AlN thin films on an LTCC (low temperature co-fired ceramics) substrate by pulsed dc reactive magnetron sputtering and the limited characterization focusing on microstructure and crystal orientation. The main focus will be placed on the effects of changing pulsed frequency. The AlN thin film showed good adhesion with the substrate and columnar structures having small grains regardless of pulsed frequency. The crystal orientation of AlN thin films was dependent on pulsed frequency according to the result of XRD patterns. The preferred (002) orientation was obtained at a pulsed frequency of 100 kHz. The broad band of 300 to 650 nm observed in photoluminescence spectrum was believed due to defects associated with the presence of oxygen impurities.
Three approaches that have been used to investigate assemblage diversity in the archaeological literature-two established and one new-are studied, with a particular emphasis on assemblage richness. It is argued that the established regression and simulation approaches, as often used, are only strictly valid if they assume what they are supposed to test-namely that assemblages are sampled from populations with the same richness or structure. Rarefaction methodology provides an alternative to the simulation approach and suggests that even if the latter is used, sampling without rather than with replacement is preferable. Some potential limitations of a recently proposed approach using jackknife methods are noted, and it is suggested that bootstrapping may be a more natural resampling method to use.