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A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
An experiment was carried out to examine the effects of offering beef cattle five silage diets. These were perennial ryegrass silage (PRGS) as the sole forage, tall fescue/perennial ryegrass silage (FGS) as the sole forage, PRGS in a 50:50 ratio on a dry matter (DM) basis with lupin/triticale silage (LTS), lupin/wheat silage (LWS) and pea/oat silage (POS). Each of the five silage diets was supplemented with 4 and 7 kg of concentrates/head/day in a five silages × two concentrate intakes factorial design. A total of 90 cattle were used in the 121-day experiment. The grass silages were of medium digestibility and were well preserved. The legume/cereal silages had high ammonia N, high acetic acid, low lactic acid, low butyric acid and low digestible organic matter concentrations (542, 562 and 502 g/kg DM for LTS, LWS and POS, respectively). Silage treatment did not significantly affect liveweight gain, carcass gain, carcass characteristics, the instrumental assessment of meat quality or fatty acid composition of the M. longissimus dorsi muscle. In view of the low yields of the legume/cereal crops, it is concluded that the inclusion of spring-sown legume/cereal silages in the diets of beef cattle is unlikely to be advantageous.
An experiment was carried out to examine the effects of offering beef steers grass silage (GS) as the sole forage, lupins/triticale silage (LTS) as the sole forage, a mixture of LTS and GS at a ratio of 70:30 on a dry matter (DM) basis, vetch/barley silage (VBS) as the sole forage, a mixture of VBS and GS at a ratio of 70:30 on a DM basis, giving a total of five silage diets. Each of the five silage diets was supplemented with 2 and 5 kg of concentrates/head/day in a 5 × 2 factorial design to evaluate the five silages at two levels of concentrate intake and to examine possible interactions between silage type and concentrate intake. A total of 80 beef steers were used in the 122-day experiment. The GS was well preserved while the whole crop cereal/legume silages had high ammonia-nitrogen (N) concentrations, low lactic acid concentrations and low butyric acid concentrations For GS, LTS, LTS/GS, VBS and VBS/GS, respectively, silage DM intakes were 6.5, 7.0, 7.2, 6.1 and 6.6 (s.e.d. 0.55) kg/day and live weight gains were 0.94, 0.72, 0.63, 0.65 and 0.73 (s.e.d. 0.076) kg/day. Silage type did not affect carcass fatness, the colour or tenderness of meat or the fatty acid composition of the intramuscular fat in the longissimus dorsi muscle.
Early detection of karyotype abnormalities, including aneuploidy, could aid producers in identifying animals which, for example, would not be suitable candidate parents. Genome-wide genetic marker data in the form of single nucleotide polymorphisms (SNPs) are now being routinely generated on animals. The objective of the present study was to describe the statistics that could be generated from the allele intensity values from such SNP data to diagnose karyotype abnormalities; of particular interest was whether detection of aneuploidy was possible with both commonly used genotyping platforms in agricultural species, namely the Applied BiosystemsTM AxiomTM and the Illumina platform. The hypothesis was tested using a case study of a set of dizygotic X-chromosome monosomy 53,X sheep twins. Genome-wide SNP data were available from the Illumina platform (11 082 autosomal and 191 X-chromosome SNPs) on 1848 male and 8954 female sheep and available from the AxiomTM platform (11 128 autosomal and 68 X-chromosome SNPs) on 383 female sheep. Genotype allele intensity values, either as their original raw values or transformed to logarithm intensity ratio (LRR), were used to accurately diagnose two dizygotic (i.e. fraternal) twin 53,X sheep, both of which received their single X chromosome from their sire. This is the first reported case of 53,X dizygotic twins in any species. Relative to the X-chromosome SNP genotype mean allele intensity values of normal females, the mean allele intensity value of SNP genotypes on the X chromosome of the two females monosomic for the X chromosome was 7.45 to 12.4 standard deviations less, and were easily detectable using either the AxiomTM or Illumina genotype platform; the next lowest mean allele intensity value of a female was 4.71 or 3.3 standard deviations less than the population mean depending on the platform used. Both 53,X females could also be detected based on the genotype LRR although this was more easily detectable when comparing the mean LRR of the X chromosome of each female to the mean LRR of their respective autosomes. On autopsy, the ovaries of the two sheep were small for their age and evidence of prior ovulation was not appreciated. In both sheep, the density of primordial follicles in the ovarian cortex was lower than normally found in ovine ovaries and primary follicle development was not observed. Mammary gland development was very limited. Results substantiate previous studies in other species that aneuploidy can be readily detected using SNP genotype allele intensity values generally already available, and the approach proposed in the present study was agnostic to genotype platform.
To investigate the effectiveness and usability of automated procedural guidance during virtual temporal bone surgery.
Two randomised controlled trials were performed to evaluate the effectiveness, for medical students, of two presentation modalities of automated real-time procedural guidance in virtual reality simulation: full and step-by-step visual presentation of drillable areas. Presentation modality effectiveness was determined through a comparison of participants’ dissection quality, evaluated by a blinded otologist, using a validated assessment scale.
While the provision of automated guidance on procedure improved performance (full presentation, p = 0.03; step-by-step presentation, p < 0.001), usage of the two different presentation modalities was vastly different (full presentation, 3.73 per cent; step-by-step presentation, 60.40 per cent).
Automated procedural guidance in virtual temporal bone surgery is effective in improving trainee performance. Step-by-step presentation of procedural guidance was engaging, and therefore more likely to be used by the participants.
We sought to identify and review published studies that discuss the ethical considerations, from a physician’s perspective, of managing a hunger strike in a prison setting.
A database search was conducted to identify relevant publications. We included case studies, case series, guidelines and review articles published over a 20-year period. Non-English language publications were translated.
The review found 23 papers from 12 jurisdictions published in five languages suitable for inclusion.
Key themes from included publications are identified and summarised in the context of accepted guidelines from the World Medical Association. Whilst there seems to be an overall consensus favouring autonomy over beneficence, tensions along this fine balance are magnified in jurisdictions where legislation leads to a dual loyalty conflict for the physician.
Many medications administered to patients with schizophrenia possess anticholinergic properties. When aggregated, pharmacological treatments may result in a considerable anticholinergic burden. The extent to which anticholinergic burden has a deleterious effect on cognition and impairs ability to participate in and benefit from psychosocial treatments is unknown.
Seventy patients were followed for approximately 3 years. The MATRICS consensus cognitive battery (MCCB) was administered at baseline. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. Ability to benefit from psychosocial programmes was measured using the DUNDRUM-3 Programme Completion Scale (D-3) at baseline and follow-up. Psychiatric symptoms were measured using the PANSS. Total antipsychotic dose was measured using chlorpromazine equivalents. Functioning was measured using the Social and Occupational Functioning Assessment Scale (SOFAS).
Mediation analysis found that the influence of anticholinergic burden on ability to participate and benefit from psychosocial programmes was completely mediated by the MCCB. For every 1-unit increase on the ACB scale, change scores for DUNDRUM-3 decreased by −0.27 points. This relationship appears specific to anticholinergic burden and not total antipsychotic dose. Moreover, mediation appears to be specific to cognition and not psychopathology. Baseline functioning also acted as mediator but only when MCCB was not controlled for.
Anticholinergic burden has a significant impact on patients’ ability to participate in and benefit from psychosocial treatment programmes. Physicians need to be mindful of the cumulative effect that medications can have on patient cognition, functional capacity and ability to benefit from psychosocial treatments.
Despite documented increases in emergency department (ED) mental health (MH) presentations, there are inconsistent findings on the characteristics of patients with repeat presentations to pediatric EDs (PEDs) for MH concerns. Our study sought to explore the characteristics of MH patients with repeat PED visits and determine predictors of return visits, of earlier repeat visits, and of more frequent repeat visits.
We examined data collected prospectively in a clinical database looking at MH presentations to a crisis intervention program housed within a PED from October 2006 to December 2011. Predictive models based on demographic and clinical variables were constructed using logistic, Cox, and negative binomial regression.
A total of 4,080 presentations to the PED were made by the 2,900 children and youth. Repeat visits accounted for almost half (45.8%) of all presentations. Multivariable analysis identified five variables that independently predicted greater odds of having repeat presentations, greater risk of earlier repeat presentations, and greater risk of frequent repeat presentations. The five variables were: female, living in the metropolitan community close to the PED, being in the care of child protective services, taking psychotropic medications, and presenting with an actionable need in the area of mood disturbances.
Repeat visits account for a large portion of all MH presentations to the PED. Furthermore, several patient characteristics are significant predictors of repeat PED use and of repeating use sooner and more frequently. Further research is needed to examine interventions targeting this patient group to ensure appropriate MH patient management.
Healthy calves are fundamental to any profitable dairy enterprise. Research to-date, has focused on year-round calving systems which experience many different challenges compared to spring-calving systems. The objective of the present study was to determine the on-farm dry cow, calving, and colostrum management practices of spring-calving dairy production systems, and quantify their associations with herd size and herd expansion status (i.e. expanding or not expanding). Information on these management practices was available from a survey of 262 Irish spring-calving dairy farmers, representative of the Irish national population. Herd expansion in the 2 years before, and the year that the survey was conducted was not associated with any of the management practices investigated. Fifty-three percent of respondents had an average calving season length of 10 to14 weeks with 35% of herds having a longer calving season. Previous research in cattle has documented that both colostrum source and feeding management are associated with the transmission of infectious disease from cow to calf. In the present study 60% of respondents fed calves colostrum from their own dam; however, 66% of those respondents allowed the calf to suckle the dam, 23% of survey respondents fed calves pooled colostrum. Larger herds were more likely (P<0.01) to use pooled colostrum supplies, while smaller herds were more likely (P<0.05) to allow the calf to suckle the dam. The majority (86%) of respondents had stored supplies of colostrum; average-sized herds had the greatest likelihood of storing colostrum (P<0.05), compared to other herd sizes; larger sized herds had a lesser likelihood (P<0.05) of storing colostrum in a freezer, compared to other herd sizes. Although freezing colostrum was the most common method used to store colostrum (54% of respondents), 17% of respondents stored colostrum at room temperature, 29% of which stored it at room temperature for greater than 4 days. The results from the present study indicate that a particular focus needs to be placed on calving and colostrum management because this study has highlighted a number of areas which are below international standards, and may have repercussions for calf health. Furthermore, management practices on larger farms could be improved and, as these represent the future of dairy farming, a focus needs to be placed on them. Expanding herds are not a particular concern as herd expansion, independent of herd size, does not seem to be associated with calving and colostrum management practices on Irish spring-calving dairy herds.
To evaluate the histopathological findings from post-treatment neck dissection of p16 positive and negative oropharyngeal carcinoma cases, after completion of chemoradiotherapy, and to question the role of neck dissection after a ‘clinically complete response’ to chemoradiotherapy.
Data were collected retrospectively from a cohort of patients treated with curative intent using chemoradiotherapy and post-treatment neck dissection. Primary tumours underwent p16 immunohistochemistry. Neck dissection specimens were examined for viable cancer cells.
A total of 76 cases were assessed. Viable cancer cells were detected from neck dissection in 29 per cent of p16 negative cases. Locoregional recurrence occurred in 12.9 per cent of p16 negative cases. The association between p16 positivity in the primary tumour and histopathologically negative neck dissection was significant (p < 0.05).
p16 status appeared to be an independent marker of disease control for the cohort in this study. The data raise questions about the role of post-treatment neck dissection in p16 positive cases with a ‘clinically complete response’ to chemoradiotherapy.
Although usually thought of as external environmental stressors, a significant heritable component has been reported for measures of stressful life events (SLEs) in twin studies.
We examined the variance in SLEs captured by common genetic variants from a genome-wide association study (GWAS) of 2578 individuals. Genome-wide complex trait analysis (GCTA) was used to estimate the phenotypic variance tagged by single nucleotide polymorphisms (SNPs). We also performed a GWAS on the number of SLEs, and looked at correlations between siblings.
A significant proportion of variance in SLEs was captured by SNPs (30%, p = 0.04). When events were divided into those considered to be dependent or independent, an equal amount of variance was explained for both. This ‘heritability’ was in part confounded by personality measures of neuroticism and psychoticism. A GWAS for the total number of SLEs revealed one SNP that reached genome-wide significance (p = 4 × 10−8), although this association was not replicated in separate samples. Using available sibling data for 744 individuals, we also found a significant positive correlation of R2 = 0.08 in SLEs (p = 0.03).
These results provide independent validation from molecular data for the heritability of reporting environmental measures, and show that this heritability is in part due to both common variants and the confounding effect of personality.