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Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4–7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal–oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.
Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).
We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.
Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.
This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.
Steve Hindle, Foundation Director of Research at the Huntington Library, San Marino, California,Alexandra Shepard, Reader in History, University of Glasgow,John Walter, Professor of History, University of Essex
Samuel Payne was baptised in the mid-Essex village of Terling on 1 August 1736, the fifth child of Robert and Mary Payne. After marrying in 1757 or 1758, he and his wife Sarah went on to have twelve children between 1759 and 1778, including (remarkably) three sets of twins: Hannah and Mary, baptised in June 1768, Joseph and John, baptised in June 1770, and Rhoda and Amelia, baptised in August 1773. This exceptional fertility left the Paynes heavily dependent on relief from the parish throughout the period. Samuel received relief during bouts of ‘sickness’ in each winter between 1767 and 1771, in the summer of 1773, the spring of 1776, and the late summer of 1781. Similarly, Sarah was incapacitated by her repeated pregnancies, requiring assistance in 1766, 1768, from March to December 1770, 1772 and 1773, and the summers of 1776 and 1778, coinciding with the birth of her last two children. By the time Samuel died, aged fifty-two, in January 1789, only nine of these children survived, but they and their mother continued to depend on occasional relief payments until at least 1801. Indeed, Sarah's son Robert followed his father, and his paternal grandfather and namesake, in sometimes requiring poor relief to support his family, as he struggled to make ends meet in the very difficult years at the turn of the nineteenth century.
In the development of novel materials for enhanced photovoltaic (PV) performance, it is critical to have quantitative knowledge of the initial performance, as well as the performance of these materials over the required 25-year lifetime of the PV system. Lifetime and degradation science (L&DS) allows for the development of new metrology and metrics, coupled to degradation mechanisms and rates. Induced absorbance to dose (IAD), a new metric being developed for solar radiation durability studies of solar and environmentally exposed photovoltaic materials, is defined as the rate of photodarkening or photobleaching of a material as a function of total absorbed solar radiation dose. In a reliability engineering framework, these quantitative degradation rates can be determined at various solar irradiances making possible real time and accelerated testing. The potential to predict power losses in a photovoltaic system over time caused by the accumulation of this kind of degradation can be calculated for real time applications or extrapolated for accelerated exposure conditions. Three formulations of poly (methyl methacrylate) (PMMA) used for mirror augmented PV systems were analyzed for the changes in IAD after accelerated testing.
Although antipsychotic medication is the first line of treatment for schizophrenia, many service users choose to refuse or discontinue their pharmacological treatment. Cognitive therapy (CT) has been shown to be effective when delivered in combination with antipsychotic medication, but has yet to be formally evaluated in its absence. This study evaluates CT for people with psychotic disorders who have not been taking antipsychotic medication for at least 6 months.
Twenty participants with schizophrenia spectrum disorders received CT in an open trial. Our primary outcome was psychiatric symptoms measured using the Positive and Negative Syndromes Scale (PANSS), which was administered at baseline, 9 months (end of treatment) and 15 months (follow-up). Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning.
T tests and Wilcoxon's signed ranks tests revealed significant beneficial effects on all primary and secondary outcomes at end of treatment and follow-up, with the exception of self-rated recovery at end of treatment. Cohen's d effect sizes were moderate to large [for PANSS total, d=0.85, 95% confidence interval (CI) 0.32–1.35 at end of treatment; d=1.26, 95% CI 0.66–1.84 at follow-up]. A response rate analysis found that 35% and 50% of participants achieved at least a 50% reduction in PANSS total scores by end of therapy and follow-up respectively. No patients deteriorated significantly.
This study provides preliminary evidence that CT is an acceptable and effective treatment for people with psychosis who choose not to take antipsychotic medication. An adequately powered randomized controlled trial is warranted.
Valence electron energy-loss (EEL) spectroscopy in a dedicated scanning transmission electron microscope (STEM) has been used to study the Σ11 grain boundary in α-A12O3 in comparison with bulk α-A12O3. The interband transition strength was derived by Kramers-Kronig analysis and the electronic structure followed from quantitative critical point (CP) modelling. Thereby differences in the acquired spectra were related quantitatively to differences in the electronic structure at the grain boundary. The band gap at the boundary was slightly reduced and the ionicity increased. This work demonstrates for the first time that quantitative analysis of spatially resolved (SR) valence EEL spectra is possible. This represents a new avenue to electronic structure information from localized structures.
KTiOPO4 (KTP) is a nonlinear optical crystal presently used for second harmonic generation and electro-optic applications. The properties (ionic conductivity and damage susceptibility) of KTP crystals can vary depending on the specific technique and conditions used for growth. Consistent defect mechanisms have been determined to explain the observed AC conductivity and damage results of KTP grown by the flux and high and low temperature hydrothermal techniques. The presence of nonstoichiometry on the K and O sublattices in KTP, increasing in magnitude with temperature, is proposed. Using these defect mechanisms, the predominant defects compensating for the formation of vacant potassium sites (VK's) in flux and hydrothermal materials are vacant oxygen sites (VO's) and OH−'s, respectively. The presence of a more varied distribution of OH− sites at room temperature in high temperature hydrothermal material with higher AC conductivity indicates the importance of specific OH− sites in the lattice that may enhance the mobility of ionic carriers. The correlation of higher AC conductivity to increased average current and damage in electric field treated KTP is explained on the basis of the proposed compensating defects (VO 's and OH− 's) which set the [VK] and [Ti3+]. The similarity of the linear optical properties of KTP grown by the various techniques is confirmed by the insensitivity of the absorption edge to the nonstoichiometry or defects present.
Dangling bond defects are created during positive bias stress of amorphous silicon thin film transistors and there is an energy barrier between 0.9 and 1 eV for this process. We have studied how this energy barrier depends on the material parameters of the amorphous silicon, namely hydrogen content, hydrogen bonding, Urbach energy and intrinsic, deposition induced stress. We observe no dependence on the hydrogen content or hydrogen bonding type, but we do observe a clear dependence on the Urbach energy and the intrinsic stress. These measurements support a localized model for defect creation involving Si-Si bond breaking and the switching of a neighboring H atom to stabilize the broken bond. These results suggest that stable amorphous silicon TFTs can be obtained at low deposition temperatures by control of the deposition-induced, intrinsic stress.
The interfacial electronic structure, presented as the interband transition strength Jcv(ω) of the interatomic bonds, can be determined by Kramers Kronig (KK) analysis of vacuum ultraviolet (VUV) reflectance or spatially resolved valence electron energy loss (SR-VEEL) spectra. For the wetted interfaces in Si3N4, equilibrium thin glass films are formed whose thickness is determined by a force balance between attractive and repulsive force terms. KK analysis of Jcv(ω) to yield ξ(ξ) for the phases present, permits the direct calculation of the configuration-dependent Hamaker constants for the attractive vdW forces from the interfacial electronic structure.
Interband transition strengths and full spectral Hamaker constants for Si3N4 samples containing a SiYA1ON glass have been determined using SR-VEELS from grains and grain boundaries and compared with results from bulk VUV spectroscopy on separate samples of glass and nitride. The At2, Hamaker constant for Si3N4 with glass of the bulk composition is 8 zJ (zJ = 10−21 J) from the more established optical method. The EELS method permits the determination of vdW forces based upon actual local compositions and structure, which may differ noticeably from bulk standards. Current results show that full spectral Hamaker constants determined from VUV and SR-VEEL measurements of uniform bulk samples agree, but care must be taken in the single scattering and zero loss subtraction corrections, and more work is ongoing in this area. Still the results show that for the grain boundary films present in these polycrystalline Si3N4 samples the glass composition is of lower index of refraction. This can arise from increased oxygen content in the intergranular glass and leads to an increased value of the Hamaker constant (24 zJ) determined in situ from the SR-VEELS of a particular grain boundary film.
We present a novel process methodology for the controlled cutting of nanotubes and other nanostructures to well-controlled lengths and sizes. The continuing increase in complexity of electronic devices, coupled with decreasing size of individual elements, are placing more stringent demands on the resolution and accuracy of fabrication patterns. The ability to fabricate on a nanometer scale guarantees a continuation in miniaturization of functional devices. Particularly interesting is the application of nanotubes' chemical and electronic properties which vary with their dimensions and structure. One realization of this process includes the use of photolithography or electron beam lithography to place protective resist patterns over the nanostructures to be cut. Those sections which are not covered by the resist pattern are removed by reactive ion etching. This is a scaleable process which permits the simultaneous cutting of many nanostructures and ensembles of nanostructures. The lengths, shapes or length distributions can be predicted from theory and thus specified for a given application requirement. Nanostructures which can be cut in this process include nanotubes, nanofibers and nanoplanes. Large scale production of nanostructures with uniform length or specific size-distribution can be used in electronic applications such as field-emission transistors, optoelectronic elements, single electron devices and sensors.
Characterization of thin surficial films of oxides has become the focus of increased interest due to their applications in microelectronics. The ability to experimentally determine the electronic structure and optical properties of oxide materials permits the direct study of the interband transitions from the valence to the conduction band states. In the past years there has been much progress in the quantitative analysis of transmission electron energy loss spectroscopy (TEELS) in the electron microscope
Here we employed reflection electron energy loss function (REELS) as well as vacuum ultraviolet (VUV) spectroscopy to determine the dielectric functions of oxide materials, i.e. Al2O3, ZrO2 and SrTiO3. The two main steps in the analysis are the removal of the effects of multiple scattering from the REELS spectra followed by application of the Kramers-Kronig dispersion transforms to the single scattering energy loss function to determine the conjugate optical variable and then the complex dielectric function. The surface and bulk plasma resonance spectra for these oxide materials have been determined from VUV and REELS, along with the influence of primary electron energy on the REELS results. The relative contribution of surface and bulk plasmon oscillation in REELS has been investigated. Comparison with VUV results and existing TEELS results indicate that Kramers-Kronig analysis can also be applied to REELS spectra and the corresponding conjugate optical properties can be obtained. Quantitative studies of the electronic structure and optical properties of thin surficial films using VUV and REELS or TEELS, represent a new avenue to determine the properties of these increasingly important films.
Decline in social functioning occurs in individuals who later develop psychosis.
To investigate whether baseline differences in disability are present in those who do and those who do not make a transition to psychosis in a group clinically at high risk and whether disability is a risk factor for transition.
Prospective multicentre, naturalistic field study with an 18-month follow-up period on 245 help-seeking individuals clinically at high risk. Disability was assessed with the Disability Assessment Schedule of the World Health Organization (WHODAS–II).
At baseline, the transition group displayed significantly greater difficulties in making new friends (z =−3.40, P = 0.001), maintaining a friendship (z =−3.00, P = 0.003), dealing with people they do not know (z =−2.28, P = 0.023) and joining community activities (z =−2.0, P = 0.05) compared with the non-transition group. In Cox regression, difficulties in getting along with people significantly contributed to the prediction of transition to psychosis in our sample (β = 0.569, s.e. = 0.184, Wald = 9.548, P = 0.002, hazard ratio (HR) = 1.767, 95% CI 1.238–2.550).
Certain domains of social disability might contribute to the prediction of psychosis in a sample clinically at high risk.
The ‘middle sort of people’ is a social group that has been the subject of increased
historical research in the last decade. Many studies have been written, and many definitions offered of
the group, its identity, and its membership. As a result, these overlapping groups and contrasting
methods of definition have caused the nature and identity of the group to remain elusive. This study
charts the evolution of the historiography of the ‘middle sort’, and the many attempts to produce
positive and accurate definitions of the group. It suggests that the identity of the ‘middle sort’ may,
in fact, be more complex than is allowed for by existing studies, with different identities being adopted
according to social context. It concludes that while the term ‘middle sort of people’ is an appropriate
contemporary collective term for use by historians, it is much more problematic as a description of an
active, cohesive social group in the early modern period.
Clostridium perfringens isolates are currently classified into one of five biotypes on the basis of
the differential production of α-, β-, ε- and ι-toxins. Different biotypes are associated with
different diseases of man and animals. In this study a multiple PCR assay was developed to
detect the genes encoding these toxins. In addition, detection of the genes encoding the C.
perfringens enterotoxin and β2-toxin allowed subtyping of the bacteria. C. perfringens isolates
taken from a variety of animals, including foals, piglets or lambs, were genotyped using this
assay. Most of the isolates were found to be genotype A and the gene encoding β-toxin was
present in 50% of the isolates genotyped. A significant association between C. perfringens
possessing the β2-toxin gene and diarrhoea in piglets was identified, suggesting that β2-toxin
may play a key role in the pathogenesis of the disease.
The quantitative study of English land markets in the three centuries after
the close of the middle ages is still in its infancy. The medievalists,
exploiting the conveyances of customary tenants recorded in manorial
court rolls, have shown how issues such as the devolution of land within
families, the frequency with which land was sold and the behaviour of the
land market at moments of demographic or economic stress can be
addressed by the analysis of such data either aggregatively or by looking
at the landholding histories of individual participants in the land market.
Early modernists have invariably approached the study of the land market
in a non-quantitative fashion, usually as part of an attempt to make
observations about some other characteristic of English history. Stone
looked at the land market in the sixteenth and early seventeenth centuries
as part of his campaign to prove that the aristocracy was in decline,
Macfarlane to show that the property-holding behaviour of the English
was ‘individualistic’, Habbakuk to explore the strategies by which the
English aristocracy maintained its supremacy and Mingay and others to
settle the debate about the effect of enclosure on the small landowner.
The early modern land market has rarely, if ever, been seen as worthy of
discussion in its own right.