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Background: The aim of this study was to investigate intraoperative methods to generate patient-specific PMMA bone implants during a craniotomy. The proposed methods combine a cost-efficient, and non-invasive structured light scanner (SLS) as an imaging modality and a prototype printer for rapid generation of implant molds. Methods: This simulation study was performed using retrospective data from three craniotomy patients. The extracted bone flap and the cranial defect were scanned using a SLS, which generates a 3D surface model of an object by projecting a series of light-patterns on it. Prototype printed implant models were generated using two different techniques. The molds were then used to shape PMMA bone implants. These implants were evaluated regarding their accuracy to reconstruct the natural skull anatomy and compared to freehand formed implants. Results: The patient-specific bone implants reconstructed the preoperative anatomy with an average RMS error of 1.37mm (StDev 0.27), compared to an error of 1.5mm (StDev 0.43) for the freehand shaped implants. On average the intraoperative scanning time was 4.7min. The average time to generate and print the implant molds was 204 min. Conclusions: Results of this study have shown great promise for the proposed method to be used for patient-specific bone flap reconstruction during craniotomies.
We propose that pressure anisotropy causes weakly collisional turbulent plasmas to self-organize so as to resist changes in magnetic-field strength. We term this effect ‘magneto-immutability’ by analogy with incompressibility (resistance to changes in pressure). The effect is important when the pressure anisotropy becomes comparable to the magnetic pressure, suggesting that in collisionless, weakly magnetized (high-
) plasmas its dynamical relevance is similar to that of incompressibility. Simulations of magnetized turbulence using the weakly collisional Braginskii model show that magneto-immutable turbulence is surprisingly similar, in most statistical measures, to critically balanced magnetohydrodynamic turbulence. However, in order to minimize magnetic-field variation, the flow direction becomes more constrained than in magnetohydrodynamics, and the turbulence is more strongly dominated by magnetic energy (a non-zero ‘residual energy’). These effects represent key differences between pressure-anisotropic and fluid turbulence, and should be observable in the
turbulent solar wind.
We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling.
Prospective, patient-level surveillance program of incident VRE colonization.
Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.
All patients admitted to the SICU from June to August 2015.
We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test.
In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001).
We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.
We present a theoretical framework for describing electromagnetic kinetic turbulence in a multi-species, magnetized, pressure-anisotropic plasma. The turbulent fluctuations are assumed to be small compared to the mean field, to be spatially anisotropic with respect to it and to have frequencies small compared to the ion cyclotron frequency. At scales above the ion-Larmor radius, the theory reduces to the pressure-anisotropic generalization of kinetic reduced magnetohydrodynamics (KRMHD) formulated by Kunz et al. (J. Plasma Phys., vol. 81, 2015, 325810501). At scales at and below the ion-Larmor radius, three main objectives are achieved. First, we analyse the linear response of the pressure-anisotropic gyrokinetic system, and show it to be a generalization of previously explored limits. The effects of pressure anisotropy on the stability and collisionless damping of Alfvénic and compressive fluctuations are highlighted, with attention paid to the spectral location and width of the frequency jump that occurs as Alfvén waves transition into kinetic Alfvén waves. Secondly, we derive and discuss a very general gyrokinetic free-energy conservation law, which captures both the KRMHD free-energy conservation at long wavelengths and dual cascades of kinetic Alfvén waves and ion entropy at sub-ion-Larmor scales. We show that non-Maxwellian features in the distribution function change the amount of phase mixing and the efficiency of magnetic stresses, and thus influence the partitioning of free energy amongst the cascade channels. Thirdly, a simple model is used to show that pressure anisotropy, even within the bounds imposed on it by firehose and mirror instabilities, can cause order-of-magnitude variations in the ion-to-electron heating ratio due to the dissipation of Alfvénic turbulence. Our theory provides a foundation for determining how pressure anisotropy affects turbulent fluctuation spectra, the differential heating of particle species and the ratio of parallel and perpendicular phase mixing in space and astrophysical plasmas.
In collisionless and weakly collisional plasmas, such as hot accretion flows onto compact objects, the magnetorotational instability (MRI) can differ significantly from the standard (collisional) MRI. In particular, pressure anisotropy with respect to the local magnetic-field direction can both change the linear MRI dispersion relation and cause nonlinear modifications to the mode structure and growth rate, even when the field and flow perturbations are very small. This work studies these pressure-anisotropy-induced nonlinearities in the weakly nonlinear, high-ion-beta regime, before the MRI saturates into strong turbulence. Our goal is to better understand how the saturation of the MRI in a low-collisionality plasma might differ from that in the collisional regime. We focus on two key effects: (i) the direct impact of self-induced pressure-anisotropy nonlinearities on the evolution of an MRI mode, and (ii) the influence of pressure anisotropy on the ‘parasitic instabilities’ that are suspected to cause the mode to break up into turbulence. Our main conclusions are: (i) The mirror instability regulates the pressure anisotropy in such a way that the linear MRI in a collisionless plasma is an approximate nonlinear solution once the mode amplitude becomes larger than the background field (just as in magnetohyrodynamics). This implies that differences between the collisionless and collisional MRI become unimportant at large amplitudes. (ii) The break up of large-amplitude MRI modes into turbulence via parasitic instabilities is similar in collisionless and collisional plasmas. Together, these conclusions suggest that the route to magnetorotational turbulence in a collisionless plasma may well be similar to that in a collisional plasma, as suggested by recent kinetic simulations. As a supplement to these findings, we offer guidance for the design of future kinetic simulations of magnetorotational turbulence.
Vancomycin-resistant enterococci (VRE) infections are a public health threat associated with increased patient mortality and healthcare costs. Antibiotic usage, particularly cephalosporins, has been associated with VRE colonization and VRE bloodstream infections (VRE BSI). We examined the relationship between antimicrobial usage and incident VRE colonization at the individual patient level. Prospective, weekly surveillance was undertaken for incident VRE colonization defined by negative admission but positive surveillance swab in a medical intensive care unit over a 17-month period. Antimicrobial exposure was quantified as days of therapy (DOT)/1000 patient-days. Multiple logistic regression was used to analyse incident VRE colonization and antibiotic DOT, controlling for demographic and clinical covariates. Ninety-six percent (1398/1454) of admissions were swabbed within 24 h of intensive care unit (ICU) arrival and of the 380 patients in the ICU long enough for weekly surveillance, 83 (22%) developed incident VRE colonization. Incident colonization was associated in bivariate analysis with male gender, more previous hospital admissions, longer previous hospital stay, and use of cefepime/ceftazidime, fluconazole, azithromycin, and metronidazole (P < 0·05). After controlling for demographic and clinical covariates, metronidazole was the only antibiotic independently associated with incident VRE colonization (odds ratio 2·0, 95% confidence interval 1·2–3·3, P < 0·009). Our findings suggest that risk of incident VRE colonization differs between individual antibiotic agents and support the possibility that antimicrobial stewardship may impact VRE colonization and infection.
A theoretical framework for low-frequency electromagnetic (drift-)kinetic turbulence in a collisionless, multi-species plasma is presented. The result generalises reduced magnetohydrodynamics (RMHD) and kinetic RMHD (Schekochihin et al., Astrophys. J. Suppl. Ser., vol. 182, 2009, pp. 310–377) to the case where the mean distribution function of the plasma is pressure-anisotropic and different ion species are allowed to drift with respect to each other – a situation routinely encountered in the solar wind and presumably ubiquitous in hot dilute astrophysical plasmas such as the intracluster medium. Two main objectives are achieved. First, in a non-Maxwellian plasma, the relationships between fluctuating fields (e.g. the Alfvén ratio) are order-unity modified compared to the more commonly considered Maxwellian case, and so a quantitative theory is developed to support quantitative measurements now possible in the solar wind. Beyond these order-unity corrections, the main physical feature of low-frequency plasma turbulence survives the generalisation to non-Maxwellian distributions: Alfvénic and compressive fluctuations are energetically decoupled, with the latter passively advected by the former; the Alfvénic cascade is fluid, satisfying RMHD equations (with the Alfvén speed modified by pressure anisotropy and species drifts), whereas the compressive cascade is kinetic and subject to collisionless damping (and for a bi-Maxwellian plasma splits into three independent collisionless cascades). Secondly, the organising principle of this turbulence is elucidated in the form of a conservation law for the appropriately generalised kinetic free energy. It is shown that non-Maxwellian features in the distribution function reduce the rate of phase mixing and the efficacy of magnetic stresses, and that these changes influence the partitioning of free energy amongst the various cascade channels. As the firehose or mirror instability thresholds are approached, the dynamics of the plasma are modified so as to reduce the energetic cost of bending magnetic-field lines or of compressing/rarefying them. Finally, it is shown that this theory can be derived as a long-wavelength limit of non-Maxwellian slab gyrokinetics.
The interaction of barotropic tidal currents and baroclinic geostrophic eddies is considered theoretically and numerically to determine whether energy can be transferred to an internal wave field by this process. The eddy field evolves independently of the tide, suggesting that it acts catalytically in facilitating energy transfer from the barotropic tide to the internal wave field, without exchanging energy with the other flow components. The interaction is identically zero and no waves are generated when the barotropic tidal current is horizontally uniform. Optimal internal wave generation occurs when the scales of tide and eddy fields satisfy resonant conditions. The most efficient generation is found if the tidal current horizontal scale is comparable to that of the eddies, with a weak maximum when the scales differ by a factor of two. Thus, this process is not an effective mechanism for internal wave excitation in the deep ocean, where tidal current scales are much larger than those of eddies, but it may provide an additional source of internal waves in coastal areas where horizontal modulation of the tide by topography can be significant.
If the voids that we see today in the distribution of galaxies existed at recombination, they will leave an imprint on the cosmic microwave background (CMB). On the other hand, if these voids formed much later, their effect on the CMB will be negligible and will not be observed with the current generation of experiments. In this paper, presented at the 2004 Annual Scientific Meeting of the Astronomical Society of Australia, we discuss our ongoing investigations into voids of primordial origin. We show that if voids in the cold dark matter distribution existed at the epoch of decoupling, they could contribute significantly to the apparent rise in CMB power on small scales detected by the Cosmic Background Imager (CBI) Deep Field. Here we present our improved method for predicting the effects of primordial voids on the CMB in which we treat a void as an external source in the cold dark matter (CDM) distribution employing a Boltzmann solver. Our improved predictions include the effects of a cosmological constant (Λ) and acoustic oscillations generated by voids at early times. We find that models with relatively large voids on the last scattering surface predict too much CMB power in an Einstein–de Sitter background cosmology but could be consistent with the current CMB observations in a ΛCDM universe.
Post-conflict mental health studies in low-income countries have lacked
pre-conflict data to evaluate changes in psychiatric morbidity resulting
from political violence.
This prospective study compares mental health before and after exposure
to direct political violence during the People's War in Nepal.
An adult cohort completed the Beck Depression Inventory and Beck Anxiety
Inventory in 2000 prior to conflict violence in their community and in
2007 after the war.
Of the original 316 participants, 298 (94%) participated in the
post-conflict assessment. Depression increased from 30.9 to 40.6%.
Anxiety increased from 26.2 to 47.7%. Post-conflict post-traumatic stress
disorder (PTSD) was 14.1%. Controlling for ageing, the depression
increase was not significant. The anxiety increase showed a dose–response
association with conflict exposure when controlling for ageing and daily
stressors. No demographic group displayed unique vulnerability or
resilience to the effects of conflict exposure.
Conflict exposure should be considered in the context of other types of
psychiatric risk factors. Conflict exposure predicted increases in
anxiety whereas socioeconomic factors and non-conflict stressful life
events were the major predictors of depression. Research and
interventions in postconflict settings therefore should consider
differential trajectories for depression v. anxiety and
the importance of addressing chronic social problems ranging from poverty
to gender and ethnic/caste discrimination.
Vancomycin-resistant enterococci (VRE) have become a public health concern with implications for patient mortality and costs. Hospital antibiotic usage may impact VRE incidence, but the relationship is poorly understood. Animal investigations suggest that ceftriaxone may be associated with VRE proliferation. We measured antimicrobial usage and VRE bloodstream infection (VRE-BSI) incidence to test our hypothesis that increased ceftriaxone usage would be associated with a higher incidence of VRE-BSI.
Retrospective cohort study.
University of Alabama at Birmingham Medical Center, a 900-bed urban tertiary care hospital.
All patients admitted during the study period contributed data.
We conducted a retrospective analysis of antimicrobial usage and VRE-BSI from 2005 to 2008 (43 months). Antimicrobial usage was quantified as days of therapy (DOTs) per 1,000 patient-days. VRE-BSI incidence was calculated as cases per 1,000 patient-days. Negative binomial regression with adjustment for correlation between consecutive observations was used to measure the association between antimicrobial usage and VRE-BSI incidence at the hospital- and care-unit levels.
VRE-BSI incidence increased from 0.06 to 0.17 infections per 1,000 patient-days. Hospital VRE-BSI incidence was associated with prior-month ceftriaxone DOTs (incidence rate ratio, 1.38 per 10 DOTs; P = .005). After controlling for ceftriaxone, prior-month cephalosporin usage (class) was not predictive of VRE-BSI (P = .70). Similarly, prior-month usage of piperacillin-tazobactam, ceftazidime, cefepime, cefazolin, or vancomycin was not predictive of VRE-BSI when considered individually (P ≥ .4 for all comparisons). The final model suggests that type of intensive care unit was related to VRE-BSI incidence.
Ceftriaxone usage in the prior month, but not cephalosporin (class) or vancomycin usage, was related to VRE-BSI incidence. These findings suggest that an antimicrobial stewardship program that limits ceftriaxone may reduce nosocomial VRE-BSI incidence.
Vancomycin-resistant Enterococcus bloodstream infections (VRE-BSI) are a growing problem with few clinical trials to guide therapy. We conducted a retrospective study of management and predictors of mortality for VRE-BSI at a tertiary-care centre from January 2005 to August 2008. Univariate and multivariable analyses examined the relationship of patient characteristics and antibiotic therapy with 30-day all-cause mortality. Rates of VRE-BSI increased from 0·06 to 0·17 infections/1000 patient-days (P=0·03). For 235 patients, 30-day mortality was 34·9%. Patients were primarily treated with linezolid (44·2%) or daptomycin (36·5%). Factors associated with mortality were haemodialysis [odds ratio (OR) 3·2, 95% confidence interval (CI) 1·6–6·3, P=0·007], mechanical ventilation (OR 3·7, 95% CI 1·3–10·4, P=0·01), and malnutrition (OR 2·0, 95% CI 1·0–4·0, P=0·046). Use of linezolid, but not daptomycin (P=0·052) showed a trend towards an association with survival. In conclusion, VRE-BSI is a growing problem, associated with significant 30-day mortality. Multiple factors were associated with poor outcomes at our hospital.
Although cognitive deficits in bipolar disorder have been associated with diminished functional outcome, this relationship has been studied primarily through cross-sectional designs, and has not been studied in patients early in the course of illness. The purpose of this study was to evaluate the impact of cognitive functioning on longitudinal 6-month functional and clinical outcome in recently diagnosed clinically stable patients with bipolar disorder.
A total of 53 recently diagnosed patients with DSM-IV bipolar disorder type I were assessed within 3 months of their first manic episode using a neuropsychological battery measuring verbal/pre-morbid intellectual functioning, learning/memory, spatial/non-verbal reasoning, attention/processing speed and executive function. Functional outcome was assessed at baseline and 6 months using the Multidimensional Scale of Independent Functioning (MSIF) and DSM-IV Global Assessment of Functioning Scale (GAF). Clinical outcome was assessed with symptom ratings and by monitoring onset of new mood episodes.
Memory, particularly verbal learning/memory, was robustly associated with 6-month functional outcome on the MSIF, even after partialling out the influence of mood symptoms and substance abuse co-morbidity. Depression ratings at 6 months, but not cognitive variables, were associated with 6-month GAF scores. Cognitive functioning was not associated with 6-month clinical outcome.
Memory was associated with 6-month longitudinal functional but not clinical outcome in recently diagnosed patients with bipolar disorder. These data further support the distinction between clinical and functional outcome, and emphasize the need for identification of, and development of treatments for, cognitive impairments early in the course of bipolar disorder.
Mitigation of methanogenesis in ruminants has been an important goal for several decades. Free lauric acid, known to suppress ruminal methanogenesis, has a low palatability; therefore, in the present study the aim was to evaluate the mitigation efficacy of its esterified form (monolaurin). Further, 13C-isotope abundance (δ13C) and 13C–12C fractionation during methanogenesis and fermentation were determined to evaluate possible microbial C-isotope preferences. Using the rumen simulation technique, four basal diets, characterised either by the C3 plants grass (hay) and wheat (straw and grain), or the C4 plant (13C excess compared with C3 plants) maize (straw and grain), and a mixture of the latter two, were incubated with and without monolaurin (50 g/kg dietary DM). Added to hay, monolaurin did not significantly affect methanogenesis. When added to the other diets (P < 0·05 for the wheat-based diet) methane formation was lowered. Monolaurin decreased fibre disappearance (least effect with the hay diet), acetate:propionate ratio, and protozoal counts. Feed residues and SCFA showed the same δ13C as the diets. Methane was depleted in 13C while CO2 was enriched in 13C compared with the diets. Monolaurin addition resulted in 13C depletion of CO2 and enrichment in CH4 (the latter only in the hay diet). In conclusion, monolaurin proved to effectively decrease methanogenesis in the straw–grain diets although this effect might partly be explained by the concomitantly reduced fibre disappearance. The influence on 13C-isotope abundance and fractionation supports the hypothesis that ruminal microbes seem to differentiate to some extent between C-isotopes during methanogenesis and fermentation.
Magnetic fields can be generated during an inflationary phase in the early universe
by amplification of perturbations of the electromagnetic field. The resulting magnetic fields can have interesting field strengths if the conformal invariance of Maxwell's equations is broken. Two particular models are discussed, one based on extra dimensions and one on nonlinear electrodynamics.