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The benefit of mandibular advancement devices in patients with sleep-disordered breathing and as a potential option for obstructive sleep apnoea syndrome is well recognised. Their use in the setting of epilepsy or other seizure disorders is typically contraindicated.
A 48-year-old patient with a history of poorly controlled epilepsy and obstructive sleep apnoea syndrome was referred for ENT review for possible tracheostomy. The patient was wheelchair-bound with 24-hour continuous positive airway pressure, but sleep studies demonstrated persistent, severe episodes of apnoea and notable sleep disturbance. Sleep nasendoscopy demonstrated marked improvement on capnography with the laryngeal mask airway in situ, and this was maintained with mandibular advancement using jaw thrust following removal of the laryngeal mask airway. A mandibular advancement device was subsequently trialled; this had no subjective benefit for the patient, but the seizures resolved and control of apnoea was achieved with the combination of a mandibular advancement device and continuous positive airway pressure.
This paper highlights a novel application of mandibular advancement devices, used in combination with continuous positive airway pressure, which resulted in complete resolution of sleep deprivation and apnoea-induced epileptic events.
Conventional approaches to evidence that prioritise randomised controlled trials appear increasingly inadequate for the evaluation of complex mental health interventions. By focusing on causal mechanisms and understanding the complex interactions between interventions, patients and contexts, realist approaches offer a productive alternative. Although the approaches might be combined, substantial barriers remain.
Declaration of interest
All authors had financial support from the National Institute for Health Research Health Services and Delivery Research Programme while completing this work. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, the Medical Research Council, Central Commissioning Facility, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, the Health Services and Delivery Research Programme or the Department of Health. S.P.S. is part funded by Collaboration for Leadership in Applied Health Research and Care West Midlands. K.B. is editor of the British Journal of Psychiatry.
During the solar maximum of 1989–91 an unprecedented sequence of 13 cosmic ray ground-level enhancements (GLEs) was observed by the world-wide neutron monitor network. Of particular interest were two GLEs observed by the Australian network. The 1989 September 29 event was the largest GLE in the space era while the October 22 GLE included an highly anisotropic precursor peak.
Analysis of both these GLEs, taking into account disturbed geomagnetic conditions, shows that the particle arrivals at the earth were unusual. The September 29 GLE had significant particle propagation in the reverse direction and as the particle flux decreased following the peak the spectrum also softened. In contrast, the 1989 October 22 precursor exhibited extreme anisotropy while the particles involved in the main GLE showed a complex temporal structure possibly indicating multiple particle injection at the solar acceleration region.
The binary X-ray source GX 1 + 4 was observed during a balloon flight in 1986, November. The source was in a relatively high intensity state. Time analysis of the data shows that the pulsation period was 111.8 ± 1.0 s indicating that one or more episodes of spin-down occurred between 1980 and 1986. Folded pulse profiles are very broad with an indication of a notch at the peak. Evidence has been found for a correlation between hard X-ray intensity and phase of the proposed 304 day orbital period. The time averaged intensity since 1980 is an order of magnitude lower than during the 1970’s. A survey of the post 1980 data shows that several reversals of the period derivative have occurred. Spin-up at the rates typical of the 1970’s has been followed by a dramatic spin-down episode with dP/dt>2.4 × 10−7 s/s.
A Skylark rocket (SL727) carrying an X-ray astronomy experiment prepared by the University of Adelaide and Tasmania (UAT) was launched from Woomera at 0030 UT on July 10, 1970. The Large Magellanic Cloud (LMC) was detected during the flight, and the recent observation of structure within the Cloud is confirmed. In particular, the data support the suggestion of X-ray emission from the 30 Doradus (Tarantula) Nebula.
In this paper we derive from first principles the expected body sizes of the parasite communities that can coexist in a mammal of given body size. We use a mixture of mathematical models and known allometric relationships to examine whether host and parasite life histories constrain the diversity of parasite species that can coexist in the population of any host species. The model consists of one differential equation for each parasite species and a single density-dependent nonlinear equation for the affected host under the assumption of exploitation competition. We derive threshold conditions for the coexistence and competitive exclusion of parasite species using invasion criteria and stability analysis of the resulting equilibria. These results are then used to evaluate the range of parasites species that can invade and establish in a target host and identify the ‘optimal’ size of a parasite species for a host of a given body size; ‘optimal’ is defined as the body size of a parasite species that cannot be outcompeted by any other parasite species. The expected distributions of parasites body sizes in hosts of different sizes are then compared with those observed in empirical studies. Our analysis predicts the relative abundance of parasites of different size that establish in the host and suggests that increasing the ratio of parasite body size to host body size above a minimum threshold increases the persistence of the parasite population.
The resurgence of pertussis in some countries that maintain high vaccination coverage has drawn attention to gaps in our understanding of the epidemiological effects of pertussis vaccines. In particular, major questions surround the nature, degree and durability of vaccine protection. To address these questions, we used mechanistic transmission models to examine regional time series incidence data from Italy in the period immediately following the introduction of acellular pertussis (aP) vaccine. Our results concur with recent animal-challenge experiments wherein infections in aP-vaccinated individuals proved as transmissible as those in naive individuals but much less symptomatic. On the other hand, the data provide evidence for vaccine-driven reduction in susceptibility, which we quantify via a synthetic measure of vaccine impact. As to the precise nature of vaccine failure, the data do not allow us to distinguish between leakiness and waning of vaccine immunity, or some combination of these. Across the range of well-supported models, the nature and duration of vaccine protection, the age profile of incidence and the range of projected epidemiological futures differ substantially, underscoring the importance of the remaining unknowns. We identify key data gaps: sources of data that can supply the information needed to eliminate these remaining uncertainties.
Anterior Cervical Discectomy and Fusion (ACDF) is the gold standard treatment for cervical spondylosis but there is a lack of consensus in the literature regarding which type of bone graft is superior: autograft or allograft. The purpose of this study is to evaluate fusion after ACDF using a stand-alone intervertebral cage packed with autologous cervical bone shavings acquired during the procedure. Twenty patients that underwent single-level ACDF from 2011 to 2014 using a stand-alone polyetheretherketone (PEEK) cage were recruited. Patients were evaluated for evidence of bone fusion by plain films and CT scan. Fusion was primarily assessed by grading the level of trabecular bridging bone across the bone-graft interface. Odom’s criteria were used to assess clinical outcome. All interbody disc spaces achieved successful fusion at follow-up. A total of 80% (16/20) of patients had radiographic evidence of trabecular bone present both within and around the cage. The other 20% exhibited bridging bone within the cage but had evidence of minor radiolucent gaps and lack of bridging bone completely surrounding the cage. Eighty percent of patients reported excellent/good clinical outcomes. ACDF using a PEEK stand-alone cage with autograft bone shavings has a high rate of fusion and avoids potential complications of classic autograft harvesting and decreased allograft fusion rates.
There is little empirical evidence to indicate that dairy cow live weight affects the extent of soil damage at the hoof-soil interface during grazing on poorly drained permanent grassland. In the present study the impact of Holstein-Friesian (HF) dairy cows with a mean (±standard deviation) live weight of 570 (±61) kg were compared with Jersey × Holstein-Friesian (JX) with a mean live weight of 499 (±52) kg each at two stocking densities: mean 2·42 ± (0·062) and 2·66 (±0·079) cows/ha. Soil physical properties (bulk density, macroporosity, gravimetric water content, air-filled porosity, penetration resistance and shear strength), poaching damage (post-grazing soil surface deformation and hoof-print depth), herbage yield and milk production were measured throughout 2011 and 2012. Soil physical properties, post-grazing soil surface deformation and herbage production were not affected by dairy cow breed or by interactions between breed and stocking density. Hoof-print depth was higher in the HF treatments (39 v. 37 mm, s.e. 0·5 mm). Loading pressure imposed at the soil surface was the same for both breeds due to a direct correlation between live weight and hoof size. Poaching damage was greater at higher stocking density. Using the lighter JX cow offered little advantage in terms of lowering the negative impact of treading on soil physical properties or reducing poaching damage and no advantage in terms of herbage or milk production compared with the heavier HF cow.
Mineralized soil nitrogen (N) is an important source of N for grassland production. Some soils can supply large quantities of plant-available N through mineralization of soil organic matter. Grass grown on such soils require less fertilizer N applications per unit yield. A reliable, accurate and user-friendly method to account for soil N supply potential across a large diversity of soils and growing conditions is needed to improve N management and N recommendations over time. In the current study, the effectiveness of chemical N tests and soil properties to predict soil N supply for grass uptake across 30 Irish soil types varying in N supply potential was investigated under controlled environmental conditions. The Illinois soil N test (ISNT) combined with soil C : N ratio provided a good estimate of soil N supply in soils with low residual mineral N. Total oxidized N (TON) had the largest impact on grass dry matter (DM) yield and N uptake across the 30 soil types, declining in its influence in later growth periods. This reflected the high initial mineral N levels in these soils, which declined over time. In the current study, a model with ISNT-N, C : N and TON (log TON) best explained variability in grass DM yield and N uptake. All three rapid chemical soil tests could be performed routinely on field samples to provide an estimate of soil N supply prior to making N fertilizer application decisions. It can be concluded that these soil tests, through their assessment of soil N supply potential, can be effective tools for N management on grassland; however, field studies are needed to evaluate this under more diverse growing conditions.
The current study investigated the coupling of groundwater and surface water nitrogen (N) dynamics over 3 years, and considered intensive agricultural land-management influences over this period where the risk of N loss to water was considered high. Groundwater N (as nitrate) was monitored monthly in different strata and zones in four hillslopes, two in each of two agricultural catchments of c. 10 km2, and stream water N flux was monitored sub-hourly in the catchment outlets. Field nutrient sources were connected to surface water via groundwater; the groundwater along hillslopes was seen to be influenced spatially and temporally by management, geology and weather as observed in the concentration variability of nitrate in groundwater. Based on spatio-temporal averages of nitrate-N concentration, groundwater status was considered good (at least below a maximum acceptable concentration (MAC) of 11·3 mg/l). However, zones coincident with land-use change (ploughing and reseeding, typical of a management event in intensive landscapes), showed high spatio-temporal variability in nitrate-N concentration, exceeding the MAC temporarily, before recovering. This spatio-temporal variability highlighted the need for insight into these differences when interpreting groundwater quality data from a limited number of basin-scale sampling points and occasions. In both catchments the 3-year mean nitrate-N concentration in stream water was similar to the spatio-temporal mean concentration in groundwater. The magnitude and variability of loads, however, were more related to changes in annual runoff rather than changes in annual groundwater nitrate-N status. In one wet year, nitrate-N loads exceeded 48 kg/ha from an Arable catchment and 45 kg/ha from a grassland catchment (close to double the loss in a dry year).
Nitrification inhibitors are used in agriculture for the purpose of decreasing nitrogen (N) losses, by limiting the microbially mediated oxidation of ammonium (NH4+) to nitrate (NO3−). Successful inhibition of nitrification has been shown in numerous studies, but the extent to which inhibitors affect other N transformations in soil is largely unknown. In the present study, cattle slurry was applied to microcosms of three different grassland soils, with or without the nitrification inhibitor dicyandiamide (DCD). A solution containing NH4+ and NO3−, labelled with 15N either on the NH4+ or the NO3− part, was mixed with the slurry before application. Gross N transformation rates were estimated using a 15N tracing model. In all three soils, DCD significantly inhibited gross autotrophic nitrification, by 79–90%. Gross mineralization of recalcitrant organic N increased significantly with DCD addition in two soils, whereas gross heterotrophic nitrification from the same pool decreased with DCD addition in two soils. Fungal to bacterial ratios were not significantly affected by DCD addition. Total gross mineralization and immobilization increased significantly across the three soils when DCD was used, which suggests that DCD can cause non-target effects on soil N mineralization–immobilization turnover.
Nitrogen (N) is an essential element for plants and animals. Due to large inputs of mineral fertilizer, crop yields and livestock production in Europe have increased markedly over the last century, but as a consequence losses of reactive N to air, soil and water have intensified as well. Two different models (CAPRI and MITERRA) were used to quantify the N flows in agriculture in the European Union (EU27), at country-level and for EU27 agriculture as a whole, differentiated into 12 main food categories. The results showed that the N footprint, defined as the total N losses to the environment per unit of product, varies widely between different food categories, with substantially higher values for livestock products and the highest values for beef (c. 500 g N/kg beef), as compared to vegetable products. The lowest N footprint of c. 2 g N/kg product was calculated for sugar beet, fruits and vegetables, and potatoes. The losses of reactive N were dominated by N leaching and run-off, and ammonia volatilization, with 0·83 and 0·88 due to consumption of livestock products. The N investment factors, defined as the quantity of new reactive N required to produce one unit of N in the product varied between 1·2 kg N/kg N in product for pulses to 15–20 kg N for beef.
Anecdotally, infectious mononucleosis is considered a more severe infection than bacterial tonsillitis, requiring a longer hospital stay. However, there is little in the literature comparing the epidemiology of the two conditions. This study aimed to compare the epidemiology of bacterial tonsillitis and infectious mononucleosis, in particular any differences in the length of in-patient stay.
The hospital in-patient enquiry system was used to analyse patients admitted with bacterial tonsillitis and infectious mononucleosis between 1990 and 2009 inclusive.
There was a total of 3435 cases over the 20 years: 3064 with bacterial tonsillitis and 371 with infectious mononucleosis. The mean length of stay was 3.22 days for bacterial tonsillitis and 4.37 days for infectious mononucleosis. The median length of stay for each condition was compared using the Mann–Whitney U non-parametric test, and a significant difference detected (p < 0.001).
Patients with infectious mononucleosis have a significantly longer stay in hospital than those with bacterial tonsillitis.
There is a clear clinical need to reliably detect residual cholesteatoma after canal wall up mastoid surgery. Ideally, this would be achieved through non-invasive radiological means rather than second-look surgery, thus preventing morbidity in those patients in whom no residual disease is found.
We describe a case in which non-echo-planar, diffusion-weighted magnetic resonance imaging sequences were used pre-operatively, and compared with subsequent surgical findings. This case highlights both the potential of this increasingly popular magnetic resonance technique and also its current limitations.
Various magnetic resonance sequencing types have been employed to try to reliably detect residual cholesteatoma, each with varying success. Non-echo-planar, fast-spin echo, diffusion-weighted sequences currently appear to be the most reliable at detecting even the smallest pearl of cholesteatoma, down to 2 mm in diameter. In our unit, a propeller, diffusion-weighted image sequence is employed on a GE Signa scanner. However, both this case study and other reports show that the accuracy of the technique is not 100 per cent. This begs the question of how much one can rely on the findings of such techniques when deciding whether second-look surgery is indicated. Scan-negative patients will require continued follow up as, at the time of imaging, residual disease may not have reached a detectable size.
Using data from a cohort study conducted by the Veterinary Laboratories Agency (VLA), evidence of spatial clustering at distances up to 30 km was found for S. Agama and S. Dublin (P values of 0·001) and borderline evidence was found for spatial clustering of S. Typhimurium (P=0·077). The evolution of infection status of study farms over time was modelled using a Markov Chain model with transition probabilities describing changes in status at each of four visits, allowing for the effect of sampling visit. The degree of geographical clustering of infection, having allowed for temporal effects, was assessed by comparing the residual deviance from a model including a measure of recent neighbourhood infection levels with one excluding this variable. The number of cases arising within a defined distance and time period of an index case was higher than expected. This provides evidence for spatial and spatio-temporal clustering, which suggests either a contagious process (e.g. through direct or indirect farm-to-farm transmission) or geographically localized environmental and/or farm factors which increase the risk of infection. The results emphasize the different epidemiology of the three Salmonella serovars investigated.
Post-mortem examinations of harbour porpoises, Phocoena phocoena, regularly reveal heavy parasitic worm burdens. These same post-mortem records show varying levels of polychlorinated biphenyls (PCBs) accumulating in the blubber of porpoises. Although a number of papers have documented geospatial and temporal changes of PCBs and their detrimental effects on marine mammal health, as yet none have examined their role in determining nematode burdens in wild marine mammal populations. Using a data set consisting of harbour porpoises stranded in the UK between 1989 and 2002, we found a significant, positive association between PCB levels and nematode burdens, although the nature of the relationship was confounded with porpoise sex, age and cause of death. It was also apparent that individuals with the heaviest infestations of nematodes did not have the highest PCB level: while PCBs are important, they are clearly not the sole determinants of nematode burdens in wild populations of the harbour porpoise around the UK.
Cryptosporidium has become increasingly recognized as a pathogen responsible for outbreaks of diarrhoeal illness in both immunocompetent and immunocompromised persons. In August 2001, an Illinois hospital reported a cryptosporidiosis cluster potentially linked to a local waterpark. There were 358 case-patients identified. We conducted community-based and waterpark-based case-control studies to examine potential sources of the outbreak. We collected stool specimens from ill persons and pool water samples for microscopy and molecular analysis. Laboratory-confirmed case-patients (n=77) were more likely to have attended the waterpark [odds ratio (OR) 16·0, 95% confidence interval (CI) 3·8–66·8], had pool water in the mouth (OR 6·0, 95% CI 1·3–26·8), and swallowed pool water (OR 4·5, 95% CI 1·5–13·3) than age-matched controls. Cryptosporidium was found in stool specimens and pool water samples. The chlorine resistance of oocysts, frequent swimming exposures, high bather densities, heavy usage by diaper-aged children, and increased recognition and reporting of outbreaks are likely to have contributed to the increasing trend in number of swimming pool-associated outbreaks of cryptosporidiosis. Recommendations for disease prevention include alteration of pool design to separate toddler pool filtration systems from other pools. Implementation of education programmes could reduce the risk of faecal contamination and disease transmission.