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The evidence base for the use of ECT in children and adolescents aged under 18 years (hereafter referred to as ‘paediatric ECT’) consists of individual case reports, case series and retrospective chart reviews, but no Randomised Controlled Trials (RCTs). This limited evidence base alongside concerns about the effects of ECT on the developing brain may help explain the infrequent use of ECT by child and adolescent psychiatrists. This chapter provides a summary of the issues and considerations pertaining to use of paediatric ECT within the British Isles (United Kingdom and Republic of Ireland). Although legal aspects relating to ECT are covered in Chapter 28, some reference specific to paediatric use is made here.
Background: Biallelic variants in POLR1C are associated with POLR3-related leukodystrophy (POLR3-HLD), or 4H leukodystrophy (Hypomyelination, Hypodontia, Hypogonadotropic Hypogonadism), and Treacher Collins syndrome (TCS). The clinical spectrum of POLR3-HLD caused by variants in this gene has not been described. Methods: A cross-sectional observational study involving 25 centers worldwide was conducted between 2016 and 2018. The clinical, radiologic and molecular features of 23 unreported and previously reported cases of POLR3-HLD caused by POLR1C variants were reviewed. Results: Most participants presented between birth and age 6 years with motor difficulties. Neurological deterioration was seen during childhood, suggesting a more severe phenotype than previously described. The dental, ocular and endocrine features often seen in POLR3-HLD were not invariably present. Five patients (22%) had a combination of hypomyelinating leukodystrophy and abnormal craniofacial development, including one individual with clear TCS features. Several cases did not exhibit all the typical radiologic characteristics of POLR3-HLD. A total of 29 different pathogenic variants in POLR1C were identified, including 13 new disease-causing variants. Conclusions: Based on the largest cohort of patients to date, these results suggest novel characteristics of POLR1C-related disorder, with a spectrum of clinical involvement characterized by hypomyelinating leukodystrophy with or without abnormal craniofacial development reminiscent of TCS.
To propose a new classification of inner-ear anomalies that is more clinically oriented and surgically relevant: the SMS (Sawai Man Singh) classification of cochleovestibular malformations.
A retrospective multicentric study was conducted of 436 cochlear implantations carried out in 3 Indian tertiary care institutes. Patients with anomalous anatomy were included and classified, as per the new SMS classification, into cochleovestibular malformation types I, II, III and IV, based on cochlear morphology, modiolus and lamina cribrosa.
There were 19, 23, 8 and 4 patients with cochleovestibular malformation types I, II, III and IV, respectively. Two-year post-operative Meaningful Auditory Integration Scale scores were statistically analysed.
This new classification for inner-ear anomalies is a simpler, more practical, outcome-oriented classification that can be used to better plan the surgery. These merits make it a more uniform classification for recording results.
Introduction: Individualizing risk for stroke following a transient ischemic attack (TIA) is a topic of intense research, as existing scores are context-dependent or have not been well validated. The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk. Our objective was to prospectively validate the Canadian TIA Score in a new cohort of emergency department (ED) patients. Methods: We conducted a prospective cohort study in 14 Canadian EDs over 4 years. We enrolled consecutive adult patients with an ED visit for TIA or nondisabling stroke. Treating physicians recorded standardized clinical variables onto data collection forms. Given the ability of prompt emergency carotid endarterectomy (CEA) to prevent stroke (NNT = 3) in high risk patients, our primary outcome was the composite of subsequent stroke or CEA ≤7 days. We conducted telephone follow-up using the validated Questionnaire for Verifying Stroke Free Status at 7 and 90 days. Outcomes were adjudicated by panels of 3 local stroke experts, blinded to the index ED data collection form. Based on prior work, we estimated a sample size of 5,004 patients including 93 subsequent strokes, would yield 95% confidence bands of +/− 10% for sensitivity and likelihood ratio (LR). Our analyses assessed interval LRs (iLR) with 95% CIs. Results: We prospectively enrolled 7,569 patients with mean 68.4 +/−14.7 years and 52.4% female, of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days (total outcomes = 181). We enrolled 81.2% of eligible patients; missed patients were similar to enrolled. The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low (probability <0.2%, iLR 0.20 [95%CI 0.091-0.44]; Moderate (probability 1.3%, iLR 0.79 [0.68-0.92]; High (probability 2.6%, iLR 2.2 [1.9-2.6]. Sensitivity analysis for just stroke ≤7 days yielded similar results: Low iLR 0.17 [95%CI 0.056-0.52], Medium iLR 0.89 [0.75-1.1], High iLR 2.0 [1.6-2.4]. Conclusion: The Canadian TIA Score accurately identifies TIA patients risk for stroke/CEA ≤7 days. Patients classified as low risk can be safely discharged following a careful ED assessment with elective follow-up. Patients at moderate risk can undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up. Patients at high risk should in most cases be fully investigated and managed ideally in consultation with a stroke specialist during their index ED visit.
Stereotactic body radiotherapy (SBRT) is widely used for the treatment of stage-I non-small cell lung cancer (NSCLC). Patient-specific motion correlated with 4DCT could be essential for hypofractionated SBRT. All patients undergoing SBRT do not require motion management during the dose delivery. The objective of this study was to evaluate which patient may benefit from Gated SBRT.
Materials and methods
Treatment planning of 20 patients of stage-I NSCLC was analysed. Conventional and 4DCT scans were taken. Internal target volume as well as planning target volume (ITV and PTV) were determined in the CT data sets. PTVall phases created using 4DCT data sets and PTV15mm created using conventional CT data were compared. Also, ITVall phases were compared with ITV created from maximum intensity projections (ITVMIP). Suitability of patients for motion management-based treatment delivery was also evaluated.
The average ITVMIP to ITVall phases ratio is 1·06 indicating good agreement between them. Based on the ratio of intensity projections, 9 out of 17 patients were found suitable for our existing gated treatment.
4D CT is the main requirement in SBRT to identify the patients who can benefit from motion management during the dose delivery.
Oscillating two-stream instability (OTSI) of a high amplitude laser or a plasma wave is investigated in plasmas with strongly coupled ions. It is shown that in some parameter regime, the pressure of strongly coupled ions becomes negative, which leads to enhance the bunching of ion and concomitant destabilization of OTSI. Applications of these results to ion accelerator and inertial confinement fusion experiments are discussed.
The study primarily aimed to calculate the orientation of the cochlea pre-operatively, using high-resolution computed tomography of the temporal bone, and predict the ease of electrode insertion.
Pre-operatively, high-resolution computed tomography scans were conducted on children scheduled for cochlear implantation, and two angles, α and β, were calculated. The values of α and β were then correlated with intra-operative difficulty in insertion of the electrode array.
Ninety-six children were included in the study. Of the seven patients who had an α angle of less than 50 degrees, the surgeon experienced difficulties in electrode insertion. However, there were four patients with an α angle of more than 50 degrees for whom the surgeon also experienced difficulties in electrode insertion. In all these patients, the β angle was more than 20 degrees.
Calculation of cochlear orientation and its angle with the surgical axis (α and β) can aid the planning of surgery, particularly with regard to the cochleostomy site and preservation of residual hearing.
Rice has the lowest grain protein content (GPC) among cereals. Efforts have been made to improve GPC through the modified bulk-pedigree method of selection. A total of 1780 F8 recombinant lines were derived in the year 2013 from five different cross combinations involving two high-GPC landraces, namely ARC10075 and ARC10063, three high-yielding parents, namely Swarna, Naveen and IR64, and one parent, namely Sharbati, known for superior grain quality with high micronutrient content. Near-infrared spectroscopy was used to facilitate high-throughput selection for GPC. Significant selection differential, response to selection and non-significant differences between the predicted and observed response to selection for GPC and protein yield indicated the effectiveness of this selection process. This resulted in lines with high GPC, protein yield and desirable levels of amylose content. Further, based on high mean and stability for GPC and protein yield over the environments in the wet seasons of 2013, 2014 and the dry season of 2014, 12 elite lines were identified. Higher accumulation of glutelin fraction and non-significant change in prolamin/glutelin ratio in the grain suggested safe guarding of the nutritional value of rice grain protein of most of these identified lines. Since rice is the staple food of millions, the output of breeding for high GPC could have a significant role in alleviating protein malnutrition, especially in the developing world.
Although quality of life (QoL) is receiving increasing attention in bipolar disorder (BD) research and practice, little is known about its naturalistic trajectory. The dual aims of this study were to prospectively investigate: (a) the trajectory of QoL under guideline-driven treatment and (b) the dynamic relationship between mood symptoms and QoL.
In total, 362 patients with BD receiving guideline-driven treatment were prospectively followed at 3-month intervals for up to 5 years. Mental (Mental Component Score – MCS) and physical (Physical Component Score – PCS) QoL were measured using the self-report SF-36. Clinician-rated symptom data were recorded for mania and depression. Multilevel modelling was used to analyse MCS and PCS over time, QoL trajectories predicted by time-lagged symptoms, and symptom trajectories predicted by time-lagged QoL.
MCS exhibited a positive trajectory, while PCS worsened over time. Investigation of temporal relationships between QoL and symptoms suggested bidirectional effects: earlier depressive symptoms were negatively associated with mental QoL, and earlier manic symptoms were negatively associated with physical QoL. Importantly, earlier MCS and PCS were both negatively associated with downstream symptoms of mania and depression.
The present investigation illustrates real-world outcomes for QoL under guideline-driven BD treatment: improvements in mental QoL and decrements in physical QoL were observed. The data permitted investigation of dynamic interactions between QoL and symptoms, generating novel evidence for bidirectional effects and encouraging further research into this important interplay. Investigation of relevant time-varying covariates (e.g. medications) was beyond scope. Future research should investigate possible determinants of QoL and the interplay between symptoms and wellbeing/satisfaction-centric measures of QoL.
Influenza A(H1N1) viruses of the 2009 pandemic (A(H1N1)pdm09) continue to cause outbreaks in the post-pandemic period. During January to May 2015, an upsurge of influenza was recorded that resulted in high fatality in central India. Genetic lineage, mutations in the hemagglutinin (HA) gene and infection by quasi-species are reported to affect disease severity. The objective of this study is to present the molecular and epidemiological trends during the 2015 influenza outbreak in central India. All the referred samples were subjected to qRT–PCR for diagnosis. HA gene sequencing (23 survivors and 24 non-survivors) and cloning were performed and analyzed using Molecular Evolutionary Genomic Analyzer (MEGA 5·05). Of the 3625 tested samples, 1607 (44·3%) were positive for influenza A(H1N1)pdm09, of which 228 (14·2%) individuals succumbed to death. A significant trend was observed in positivity (P = 0·003) and mortality (P < 0·0001) with increasing age. The circulating A(H1N1)pdm09 virus was characterized as belonging to clade-6B. Clinically significant mutations were detected. Patients infected with the quasi-species of the virus had a greater risk of death (P = 0·009). This study proposes a robust molecular and clinical surveillance program for the detection and characterization of the virus, along with prompt treatment protocols to prevent outbreaks.
The interaction of laser radiation with low density aerogels is of crucial importance in areas such as the creation of coherent radiation sources in the X-ray range, simulation of astrophysical as well as nuclear fusion phenomena in laboratory and fundamental studies of the properties of soft condensed matter under dynamic pressure in the Mbar range. In the present paper, the experimental results on the X-ray emission of laser induced plasma in TEOS based, MTMS based aerogels and solid quartz targets, are reported. The aerogels were produced by the sol-gel processing of tetraethoxysilane (TEOS) and methyltrimethoxysilane (MTMS) followed by supercritical drying. Silica alcogels were produced using 0.001 M oxalic acid (C2H4O4), 0.5 M ammonium hydroxide (NH4OH) catalysts. Different densities of aerogels varying from 0.02 to 0.06 g/cm3 have been obtained using different molar ratios of TEOS, MTMS, ethanol and catalysts. The laser, with intensity up to 2 x 1014 W/m2, interaction with TEOS and MTMS based aerogels have been conducted using 30J/500 ps Nd : glass laser system. The resulting soft (0.8 – 1.56 Kev) and hard (>4 Kev) X-ray emissions have been measured using semiconductor photodiodes. It has been observed that the soft X-ray yield increases by a factor of two for the silica aerogel targets compared to the X-ray emission from the solid quartz target, whereas the hard X-ray yield reduces. The enhanced soft X-ray yield in silica aerogel targets is attributed to the large volume heating.
The Global Muon Detector Network (GMDN) is composed by four ground cosmic ray detectors distributed around the Earth: Nagoya (Japan), Hobart (Australia), Sao Martinho da Serra (Brazil) and Kuwait city (Kuwait). The network has operated since March 2006. It has been upgraded a few times, increasing its detection area. Each detector is sensitive to muons produced by the interactions of ~50 GeV Galactic Cosmic Rays (GCR) with the Earth′s atmosphere. At these energies, GCR are known to be affected by interplanetary disturbances in the vicinity of the earth. Of special interest are the interplanetary counterparts of coronal mass ejections (ICMEs) and their driven shocks because they are known to be the main origins of geomagnetic storms. It has been observed that these ICMEs produce changes in the cosmic ray gradient, which can be measured by GMDN observations. In terms of applications for space weather, some attempts have been made to use GMDN for forecasting ICME arrival at the earth with lead times of the order of few hours. Scientific space weather studies benefit the most from the GMDN network. As an example, studies have been able to determine ICME orientation at the earth using cosmic ray gradient. Such determinations are of crucial importance for southward interplanetary magnetic field estimates, as well as ICME rotation.
In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists.
We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of ‘Yes’ or ‘No’ questions to assess attitudes about mental illness, and utilized exact McNemar's test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback.
For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the training's positive impact and complementary nature of the program's components.
Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
The Gor Garung group of glaciers constitute an ice cover of over 4 km2 in a basin of 27 km2 area, lying in the Sutlej River catchment of the north–western Himalaya. This paper, the first record of these glaciers, their moraines and lakes observed in this area, is the result of mapping the glaciers and the pro–glacial field.
An attempt has been made to utilize lichenometry for establishing relative antiquity of various terminal moraine ridges generated by these glaciers, and six groups have been determined.
Filamentation is one of the most common nonlinear phenomena taking place in the laser–plasma interaction that splits the laser beam into high-intensity spikes. The present study deals with the nonlinear evolution of filamentation instability in laser–plasma interaction and the development of chaos in contrast to linear growth as reported by Kaw et al. in 1973. We have considered a non-uniform perturbation superimposed on plane-wave pump such that due to non-uniformity of the perturbation a finite intensity gradient arises and gives rise to ponderomotive force. This causes filamentation of wave, which has been studied presently using numerical methods as well as analytical tools. The results reveal that the intensity of perturbation gets localized and delocalized with the distance of propagation. The numerical simulation results also reveal that the intensity of perturbation route from ordered to chaotic behavior depending upon the pump laser and perturbation parameters. To study the chaotic behavior, Lyapunov exponents has also been calculated. The semi-analytical method is also developed to have an insight into some of the features of simulation like the formation of localized structures.
This study aimed to assess the utility of onlay pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage total laryngectomy.
A retrospective analysis was performed of 172 patients who underwent salvage laryngectomy for recurrent carcinoma of the larynx or hypopharynx between 1999 and 2014. One hundred and ten patients underwent primary closure and 62 patients had pectoralis major myofascial flap onlay.
The overall pharyngocutaneous fistula rate was 43 per cent, and was similar in both groups (primary closure group, 43.6 per cent; onlay flap group, 41.9 per cent; p = 0.8). Fistulae in the onlay flap group healed faster: the median and mean fistula duration were 37 and 55 days, respectively, in the primary closure group and 20 and 25 days, respectively, in the onlay flap group (p = 0.008).
Use of an onlay pectoralis major myofascial flap did not decrease the pharyngocutaneous fistula rate, although fistula duration was shortened. A well-designed randomised-controlled trial is needed to establish parameters for its routine use in clinical practice.
Global Value Chains (GVCs) have emerged as an extremely important form of organization of production and value creation, thanks to technological change and the process of globalization. India is rather a late comer in this system, and even now it comparatively accounts for a smaller proportion of value creation under GVCs as compared to most of middle and high income countries.
The Institute for Human Development (IHD) has been one of the few institutions in India which pioneered in creating interest in this increasingly important issue. IHD with support from ILO and Indian Council of Social Science Research (ICSSR) had organized an international conference way back in 1998 on this subject in Bangalore, selected papers of which were brought out as an edited volume. The present volume, largely an outcome of the Capturing the Gains (CtG) research programme, supported by DFID and implemented by the University of Manchester, has been coordinated by the IHD where many of the Asian case studies included in this book were conducted.
The papers in this volume bring together studies of labour and working conditions in many GVCs across Asia. Participation in GVCs has provided many benefits to Asia—increased employment in increasing return activities, such as manufacturing and services; reduction in poverty; and the enhanced participation of women in these modern sectors. This book, however, also points to the continued weaknesses and negativities in these developments such as the continuation of sweatshop conditions, even child labour, in many parts of GVC manufacture; the appearance of new forms of Taylorism in Call Centres; and so on.
There are other books and papers too dealing with issues of workers in global production networks. This book is different in its approach, it has tried to identify the positive factors that can work to improve the conditions of labour. It emphasizes the role of workers’ organizations in the new areas of worker concentration. It stresses women's entry into the modern sectors of the economy as a factor that enables them to challenge and change existing restrictive gender norms. With an increasing sphere of GVCs creating new forms of institutions, including labour market institutions is very important. This book fills an important gap on the subject, although more such analyses will be needed in future, which it will facilitate.
Introduction: About 20% of TIAs are due to large vessel disease. Carotid stenosis >50% which is causing a TIA or stroke needs to be definitely managed quickly in order to benefit. Alternatively, dual antiplatelet therapy may be considered. The objective of this study was to determine high-risk diagnostic findings associated with symptomatic carotid disease in ED patients with TIA to indicate patients requiring urgent carotid imaging. Methods: We performed a prospective Canadian multicenter cohort study, at 13 academic sites, of ED patients with TIA or non-disabling stroke from 2006-2014. Study research nurses recorded imaging findings on standardized data collection forms from the final reports of all imaging tests ordered in the ED on prospectively enrolled patients by treating emergency physicians. Symptomatic carotid disease was defined as carotid stenosis 50-99% or carotid dissection and was adjudicated by stroke neurology to be the etiology of the index event. Patients were followed by medical review and telephone up to 90 days. Univariate analysis was conducted for investigation results with our primary outcome. Results: The cohort included 305 patients with and 5,277 without symptomatic carotid disease. Positive predictors of symptomatic carotid disease included platelet count over 400 x 109/L (15.3% vs 7.6%; p=0.0095), blood glucose >15 mmol/L (11.4% vs 4.4%; p<0.0001), CT evidence of acute infarction (9.8% vs 4.1%; p<0.0001), CT evidence of old infarction (35.7% vs 24.1%; p<0.0001), and CT evidence of any infarct (43.3% vs 26.7%; p<0.0001). There were no negative predictors of symptomatic carotid disease. Conclusion: High-risk investigation findings suggestive of symptomatic carotid disease in ED TIA patients include platelet count over 400 x 109/L, blood glucose >15 mmol/L, CT evidence of any infarction. Patients with any of these findings should be considered for rapid carotid imaging.