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Anti-psychotics have been used extensively in the past for BPSD. However, since the discovery that some atypical antipsychotics may be associated with an increased risk of cerebral thrombosis, this practice has been deemed more controversial.
People with intellectual disability (ID) have higher rates of mental illness compared to the general population, including dementia. In particular, people with Down's syndrome have a higher incidence of Alzheimer's disease and an earlier age at onset, due to excess amyloid deposition in the brain. Here we describe prescribing patterns used in people with dementia ID and comorbid dementia.
We aim to show that it is possible to minimise the use of antipsychotics for BPSD in people with comorbid ID and dementia by the earlier use of anti-dementia drugs.
In some patients, we discontinued antipsychotics in favour of anti-dementia drugs to manage BPSD, whilst in others we avoided the use of antipsychotics entirely. We used the personal and social performance scale (PSP) as an outcome measure.
Our outcomes show that it is possible to manage dementia symptoms and BPSD with anti dementia drugs whilst keeping anti psychotic prescribing to a minimum.
Similar findings have been reported in people with BPSD in the general population, but such findings but have not been widely reported in the ID population.
We were able to demonstrate the feasibility of keeping antipsychotic prescribing to a minimum and still remain in control of BPSD in a small number of patients with comorbid ID and dementia.
Research has shown that Mirtazapine has been effective in stimulating appetite in the elderly. We present a case series of three patients with Moderate Intellectual Disability, each presenting with intractable refusal to eat over several months. They did not have overt symptoms of depression according to carers and family. Two patients were being considered for Percutaneous Endoscopic Gastrostomy (PEG) feeding in view of their significant weight loss and deteriorating physical health.
Mirtazapine was introduced as an appetite stimulant, despite the apparent lack of depressive symptoms. All three patients experienced an improvement in their appetite within days of initiation of Mirtazapine, increasing their calorie and fluid intake and obviating the need for PEG feeding. During the following 3 months, the patients also developed an increased interest in activities, improved sleeping pattern and improved concentration.
These patients had very limited communication skills and there was little suggestion of depression at the time of assessment. The families and carers also did not feel that their relative was significantly depressed. Despite this, Mirtazapine had the two fold benefit of early appetite stimulation and, over the subsequent weeks, treating what in hindsight had been an underlying depressive episode. A lesson to be learnt is that primary refusal to eat, even in the absence of overt depressive symptoms may indicate an occult depressive episode in this patient group. We have shown that Mirtazapine can be an effective treatment in such cases and can prevent distressing medical intervention from having to be used.
The Weaklaw vent in SE Scotland (East Lothian coast), inferred to be Namurian, produced lava spatter and volcanic bombs. The latter commonly contained ultramafic xenoliths. All were metasomatised by carbonic fluids rich in incompatible elements. The lavas and xenoliths are inferred to have been basanites and lherzolites prior to metasomatism. The abundance and size of (carbonated) peridotite xenoliths at Weaklaw denotes unusual rapidity of magma ascent and high-energy eruption making Weaklaw exceptional in the British Isles. The lavas and xenoliths were altered subsequently by low-temperature (<200°C) carbo-hydrous fluids to carbonate, clay and quartz assemblages. A small irregular tuffisite ‘dyke’ that transects the ejecta is also composed dominantly of carbonates and clays. The peridotitic xenoliths are typically foliated, interpreted as originating as pre-entrainment mantle shear-planes.
Analyses of the relic spinels shows them to be compositionally similar to spinels in local unaltered lherzolites from near-by basanitic occurrences. Chromium showed neither significant loss nor gain but was concentrated in a di-octahedral smectite allied to volkonskoite. It is in the complex association of smectite with other clays, chlorite and possibly fuchsite that the diverse incompatible elements are concentrated.
We conclude that late Palaeozoic trans-tensional fault movement caused mantle shearing. Rapid ascent of basanite magma entrained large quantities of sheared lithospheric mantle. This was followed by ascent of an aggressive carbonate-/ hydroxyl-rich fluid causing pervasive metasomatism. The vent is unique in several ways: in its remarkable clay mineralogy and in displaying such high Cr-clays in a continental intra-plate setting; in being more productive in terms of its ‘cargo’ of peridotite xenoliths; in presenting an essentially un-eroded sequence of Namurian extrusives; and, not least, for giving evidence for post-eruptive, surface release of small-melt, deep-source fluids.
In the 2015 review paper ‘Petawatt Class Lasers Worldwide’ a comprehensive overview of the current status of high-power facilities of
was presented. This was largely based on facility specifications, with some description of their uses, for instance in fundamental ultra-high-intensity interactions, secondary source generation, and inertial confinement fusion (ICF). With the 2018 Nobel Prize in Physics being awarded to Professors Donna Strickland and Gerard Mourou for the development of the technique of chirped pulse amplification (CPA), which made these lasers possible, we celebrate by providing a comprehensive update of the current status of ultra-high-power lasers and demonstrate how the technology has developed. We are now in the era of multi-petawatt facilities coming online, with 100 PW lasers being proposed and even under construction. In addition to this there is a pull towards development of industrial and multi-disciplinary applications, which demands much higher repetition rates, delivering high-average powers with higher efficiencies and the use of alternative wavelengths: mid-IR facilities. So apart from a comprehensive update of the current global status, we want to look at what technologies are to be deployed to get to these new regimes, and some of the critical issues facing their development.
Eta Carinae is the most massive active binary within 10,000 light-years. While famous for the largest non-terminal stellar explosion ever recorded, observations reveal a supermassive (∼120 M⊙) binary consisting of an LBV and either a WR or extreme O star in a very eccentric orbit (e=0.9) with a 5.54-year period. Dramatic changes across multiple wavelengths are routinely observed as the stars move about in their highly elliptical orbits, especially around periastron when the hot (∼40 kK) companion star delves deep into the denser and much cooler (∼15 kK) extended wind photosphere of the LBV primary. Many of these changes are due to a dynamic wind-wind collision region (WWCR) that forms between the stars, plus expanding radiation-illuminated fossil WWCRs formed one, two, and three 5.54-year orbital cycles ago. These fossil WWCRs have been spatially and spectrally resolved by the Hubble Space Telescope/Space Telescope Imaging Spectrograph (HST/STIS) at multiple epochs, resulting in data cubes that spatially map Eta Carinae’s innermost WWCRs and follow temporal changes in several forbidden emission lines (e.g. [Fe iii] 4659 Å, [Fe ii] 4815 Å) across the 5.54-year cycle. We present initial results of 3D time-dependent hydrodynamical and radiative-transfer simulations of the Eta Carinae binary and its WWCRs with the goal of producing synthetic data cubes of forbidden emission lines for comparison to the available HST/STIS observations. Comparison of the theoretical models to the observations reveals important details about the binary’s orbital motion, photoionization properties, and recent (5–15year) mass loss history. Such an analysis also provides a baseline for following future changes in Eta Carinae, essential for understanding the late-stage evolution of a nearby supernova progenitor. Our modeling methods can also be adapted to a number of other colliding wind binary systems (e.g. WR 140) that are scheduled to be studied with future observatories (e.g. the James Webb Space Telescope).
Introduction: Our emergency department (ED) sees a low volume of high acuity pediatric cases. A needs assessment revealed that 68% of our Emergency Physicians (EP) manage pediatric patients in less than 25% of their shifts. The same percentage of EPs as well as ED nurses indicated they were uncomfortable managing a critically unwell neonate. Thus, an interprofessional curriculum focused on pediatric emergencies for ED staff was developed. In-situ simulation education was chosen as the most appropriate method to consolidate each didactic block of curriculum, and uncover important system gaps. Methods: Needs assessment conducted, and emerging themes informed IPE curriculum objectives. A committee of experts in simulation, pediatric emergencies and nursing education designed a full-day, RCPSC accredited, interprofessional in-situ simulation program. Results: Progressive segmental strategy maximized learning outcomes. The initial phase (2 hrs) comprised an” early recognition of sepsis” seminar and 4 rotating skills stations (equipment familiarity, sedating the child, IV starts, and mixing IV medication). This deliberate, adaptive, customized practice was enhanced by expert facilitation at each station, directly engaging participants and providing real-time feedback. The second phase allowed interprofessional teams of MDs, RNs and Physician Assistants to apply knowledge gained from the didactic and skills stations to in-situ simulated emergencies. Each group participated in two pediatric emergency scenarios. Scenarios ran 20 minutes, followed by a 40 minute debrief. Each scenario had a trained debriefer and content expert. The day concluded with a final debrief, attended by all participants. Formalized checklists assessed participants knowledge translation during simulation exercises. Participants assessed facilitators and evaluated the simulation day and curriculum via anonymous feedback forms. Debriefing sessions were scribed and knowledge gaps and system errors were recorded. Results were distributed to ED leaders and responsibilities assigned to key stakeholders to ensure accountability and improvement in system errors. Results All participants reported the experience to be relevant and helpful in their learning. All participants requested more frequent simulation days. System gaps identified included: use of metric vs imperial measurements, non-compatible laryngoscope equipment, inadequate identification of team personnel. As a result, the above-mentioned equipment has been replaced, and we are developing resuscitation room ID stickers for all team roles. Conclusion: Simulation as a culmination to a didactic curriculum provides a safe environment to translate acquired knowledge, increasing ED staff comfort and familiarity with rare pediatric cases. Additionally, is an excellent tool to reveal system gaps and allow us to fill these gaps to improve departmental functioning and safety.
Introduction: Tertiary care emergency departments (EDs) in large urban environments may have a low volume of high acuity pediatric presentations due to their proximity to dedicated childrens hospitals or large community centres. This may lead to discomfort among emergency physicians (EPs) and registered nurses (RNs) in managing these patients and a waning of knowledge and skills for this unique population. Among the EP group at our institution, 68% indicated they managed pediatric patients in less than 25% of their shifts, 68% also indicated they were uncomfortable managing an undifferentiated critically unwell neonate and only 32% indicated they would be comfortable teaching pediatric topics to emergency medicine residents. At our institution, our innovation was to create a useful curriculum for certified EPs and RNs to improve the interdisciplinary teams comfort level, knowledge and skill set when managing pediatric emergencies. Methods: A needs assessment was undertaken of the EPs and RNs working in our centre. This information was used to develop intended learning outcomes in a collaborative manner with the clinical nursing educator and physician curriculum leads. The team further collaborated with the local simulation centre and a pediatric emergency physician from the local childrens hospital. Results: A one-year, three-module curriculum was developed to cover the areas felt to be highest yield by the EP group: febrile illness, respiratory disease and critically ill neonates and infants. Each module contains three components: an in person interactive lecture delivered by an EP who routinely manages pediatric patients, either at a childrens hospital or large community centre; an online component with e-mail blasts of high yield pediatric content; and, culminating in an interdisciplinary interdepartmental simulation held in situ. This latter is particularly important so that all members of the interdisciplinary team can practice finding and using equipment based on its actual location within the ED. Each component of each module is then evaluated by the participants to ensure improvement for subsequent delivery. Conclusion: Well delivered continuing professional development (CPD) will become increasingly important as competence by design becomes the model for maintenance of certification. Maintaining skills for pediatric patients is an important component of CPD for physicians working in general emergency departments that see a low volume of high acuity pediatric presentations. Our curriculum seeks to address this identified need in an innovative manner using a modular and interdisciplinary approach with a diversity of teaching methods to appeal to the learning styles among our health care team.
Eta Carinae is one of the most massive observable binaries. Yet determination of its orbital and physical parameters is hampered by obscuring winds. However the effects of the strong, colliding winds changes with phase due to the high orbital eccentricity. We wanted to improve measures of the orbital parameters and to determine the mechanisms that produce the relatively brief, phase-locked minimum as detected throughout the electromagnetic spectrum. We conducted intense monitoring of the He ii λ4686 line in η Carinae for 10 months in the year 2014, gathering ~300 high S/N spectra with ground- and space-based telescopes. We also used published spectra at the FOS4 SE polar region of the Homunculus, which views the minimum from a different direction. We used a model in which the He ii λ4686 emission is produced by two mechanisms: a) one linked to the intensity of the wind-wind collision which occurs along the whole orbit and is proportional to the inverse square of the separation between the companion stars; and b) the other produced by the ‘bore hole’ effect which occurs at phases across the periastron passage. The opacity (computed from 3D SPH simulations) as convolved with the emission reproduces the behavior of equivalent widths both for direct and reflected light. Our main results are: a) a demonstration that the He ii λ4686 light curve is exquisitely repeatable from cycle to cycle, contrary to previous claims for large changes; b) an accurate determination of the longitude of periastron, indicating that the secondary star is ‘behind’ the primary at periastron, a dispute extended over the past decade; c) a determination of the time of periastron passage, at ~4 days after the onset of the deep light curve minimum; and d) show that the minimum is simultaneous for observers at different lines of sight, indicating that it is not caused by an eclipse of the secondary star, but rather by the immersion of the wind-wind collision interior to the inner wind of the primary.
We present results from our ongoing infrared spectroscopic studies of the massive stellar content at the Center of the Milky Way. This region hosts a large number of apparently isolated massive stars as well as three of the most massive resolved young clusters in the Local Group. Our survey seeks to infer the presence of a possible top-heavy recent star formation history and to test massive star formation channels: clusters vs isolation.
A new protocol for the quantitative determination of zeolite-group mineral compositions by electron probe microanalysis (wavelength-dispersive spectrometry) under ambient conditions, is presented. The method overcomes the most serious challenges for this mineral group, including new confidence in the fundamentally important Si-Al ratio. Development tests were undertaken on a set of natural zeolite candidate reference samples, representing the compositional extremes of Na, K, Cs, Mg, Ca, Sr and Ba zeolites, to demonstrate and assess the extent of beam interaction effects on each oxide component for each mineral. These tests highlight the variability and impact of component mobility due to beam interaction, and show that it can be minimized with recommended operating conditions of 15 kV, 2 nA, a defocused, 20 μm spot size, and element prioritizing with the spectrometer configuration. The protocol represents a pragmatic solution that works, but provides scope for additional optimization where required. Vital to the determination of high-quality results is the attention to careful preparations and the employment of strict criteria for data reduction and quality control, including the monitoring and removal of non-zeolitic contaminants from the data (mainly Fe and clay phases). Essential quality criteria include the zeolite-specific parameters of R value (Si/(Si + Al + Fe3+), the 'E%' charge-balance calculation, and the weight percent of non-hydrous total oxides. When these criteria are applied in conjunction with the recommended analytical operating conditions, excellent inter-batch reproducibility is demonstrated. Application of the method to zeolites with complex solid-solution compositions is effective, enabling more precise geochemical discrimination for occurrence-composition studies. Phase validation for the reference set was conducted satisfactorily with the use of X-ray diffraction and laser-ablation inductively-coupled plasma mass spectroscopy.
Introduction: Between 1980 and 2008, survival rates following an out-of-hospital cardiac arrest (OHCA) have remained unchanged, averaging 7.6%. Despite the use of new and emerging technologies, new medications, and automated external defibrillators, survival remains low. Recently, a new focus in cardiopulmonary resuscitation (CPR) has shown dramatic improvements in survival post OHCA. This new model, called pit-crew CPR, focuses on minimizing interruptions in chest compressions and has each team member playing a specific role in the resuscitation, akin to the pit-crew of a car race. Certain districts in the United States and Canada have adopted the pit-crew, or a similar, high quality, maximum time-on-chest CPR model, with much success. We aim to determine whether the pit-crew model of CPR improves survival following OHCA in Saskatoon, SK. Methods: In Saskatoon, EMS and Fire crews respond to OHCAs and have been exclusively using the pit-crew model of CPR since Jan 1st, 2015. This study is a before and after retrospective chart analysis, comparing two groups - pre and post implementation of the pit-crew CPR model. The primary outcome is survival to hospital discharge post OHCA. Secondary outcomes include survival to admission and any return of spontaneous circulation (as per the Utstein definition). The inclusion criteria are patients >18 years old with a witnessed OHCA of presumed cardiac origin who receive CPR by EMS/Fire within the Saskatoon Ambulance service (MD Ambulance) catchment area. Patients were excluded if the OHCA was unwitnessed, or if there was a presumed non-cardiac cause for the arrest, e.g. trauma. Results: In the pre-pit-crew model cohort, between Jan 1st, 2011 and Sept 31st, 2014, 455 OHCAs were analyzed. In this cohort 10.5% survived to discharge, 31.9% survived to admission and ROSC was achieved in 39% of cases. The percentage of patients with initial rhythms of VF/VT, asystole or PEA were 28.5% (26%), 41.5% (1%) and 23.6% (10%) respectively, with survival to discharge shown in parentheses. The post-pit-crew cohort is still in the data collection phase. Conclusion: Our pre-pit crew cohort data has been collected and analyzed. With ongoing data acquisition for the post-pit crew cohort, we hope to have the full data set complete by the end of 2018. It will be at that time when we are able to determine whether the pit-crew model of CPR improves survival to discharge following OHCA in Saskatoon.
This paper uses measurements of surface heat transfer to study roughness-induced turbulent wedges in a hypersonic boundary layer on a blunt cylinder. A family of wedges was produced by changing the height of an isolated roughness element, providing conditions in the following range: fully effective tripping, for the largest element, with a turbulent wedge forming immediately downstream of the element; a long wake, in length several hundred times the boundary layer thickness, leading ultimately to transition; and retention of laminar flow, for the smallest element. With appropriate element size, a fully intermittent wedge formed, comprising a clear train of turbulent spots.
Recent detection of a large number of apparently isolated massive stars within the inner 80 pc of the Galactic Center has raised fundamental questions regarding massive star formation in a such a dense and harsh environment. Are these isolated stars the results of tidal interactions between clusters, are they escapees from a disrupted cluster, or do they represent a new mode of massive star formation in isolation? Noting that most of the isolated massive stars have spectral analogs in the Quintuplet Cluster, we have undertaken a combined analysis of the infrared spectra of both selected Quintuplet stars and the isolated objects using Gemini North spectroscopy. We present preliminary results, aiming at α-elements vs iron abundances, stellar properties, ages and radial velocities which will differentiate the top-heavy and star-formation scenarios.
This paper presents time-averaged data for high-Reynolds-number hypersonic shock-wave/boundary-layer interactions, using a body of revolution to achieve high standards of two-dimensionality. The data are collected at nominal Mach 8.9, but a calibration is included that permits weak flow gradients in the test section to be incorporated as part of the data interpretation or flow modelling. The axisymmetric turbulent test boundary layer is developed on a hollow cylinder, aligned axially with the flow. The shock-wave interaction with this boundary layer is then generated by two separate configurations. Firstly, an impinging shock-wave case, that uses a concentric cowl to radiate an axisymmetric shock system onto the test boundary layer: for this case both an attached flow and a separated flow interaction are formed. Secondly, use of a conical-flare afterbody to produce a separated flow interaction. Quantitative data are presented for surface pressures and heat transfer, supported by some schlieren visualization and surface oil flows. A restricted CFD programme is included to assist the interpretation of the experiments.
Foraminiferal analyses of 404 contiguous samples, supported by diatom, lithologic, geochronologic and seismic data, reveal both rapid and gradual Holocene paleoenvironmental changes in an 8.21-m vibracore taken from southern Pamlico Sound, North Carolina. Data record initial flooding of a latest Pleistocene river drainage and the formation of an estuary 9000 yr ago. Estuarine conditions were punctuated by two intervals of marine influence from approximately 4100 to 3700 and 1150 to 500 cal yr BP. Foraminiferal assemblages in the muddy sand facies that accumulated during these intervals contain many well-preserved benthic foraminiferal species, which occur today in open marine settings as deep as the mid shelf, and significant numbers of well-preserved planktonic foraminifera, some typical of Gulf Stream waters. We postulate that these marine-influenced units resulted from temporary destruction of the southern Outer Banks barrier islands by hurricanes. The second increase in marine influence is coeval with increased rate of sea-level rise and a peak in Atlantic tropical cyclone activity during the Medieval Climate Anomaly. This high-resolution analysis demonstrates the range of environmental variability and the rapidity of coastal change that can result from the interplay of changing climate, sea level and geomorphology in an estuarine setting.
To identify the greatest difficulties reported by people affected by neurofibromatosis type 2, and to determine the relationship between the primary and secondary effects of the disease.
Postal questionnaire study.
Questionnaire sent to subjects' home addresses.
Eighty-seven adult patients under the care of the Manchester multidisciplinary neurofibromatosis type 2 team were invited to take part.
Main outcome measure:
The response rate was 62 out of 87 (71 per cent).
Respondents' answers emphasised that their greatest problem was deafness, which resulted in communication difficulties with social contacts, close partners, family and friends. Correlation coefficients indicated a relationship between general mood changes and hearing difficulties, social communication problems, balance difficulties and mobility problems. Self-confidence was significantly related only to social communication problems.
The use of a closed set neurofibromatosis type 2 questionnaire identified hearing problems and subsequent communication difficulties as the main problems faced by people with this condition.
The purpose of this study was to DNA fingerprint the majority (64 %) of isolates received at the Pertussis Reference Laboratory during the 1993 whooping cough epidemic by pulsed field gel electrophoresis of Xba I - generated restriction digests. Two DNA restriction patterns, types 1 and 3, predominated (40% and 23%. respectively, of 180 isolates) but type 2, identified in a previous study was notably absent. Twenty-one new DNA types occurred (24% of isolates), some being atypical as bands 155–230 kb were no longer conserved, but there was no statistically significant difference in their incidence in the upswing (June-September) compared to the downswing (October-December) phase of the epidemic. There was a relatively high proportion of new types, compared to type 1. at the peak (September). About 50% of isolates received were from the North Western Region, where 44% of isolates were DNA type 1. Whereas only 1 out of 10 isolates from Scotland were of this type, suggesting some geographic variation. Statistically significant findings included a higher proportion of isolates from female patients (P < 0·01), most marked in the 12–24 months age group (P < 0·05); a higher proportion of infants under 12 months requiring hospital admission compared to older children (P < 0·05); and a greater number of isolates from unvaccinated children (P < 0·01). Analysis of serotype according to four age groups (under 3 months, 3–12 months, 12–24 months and above 2 years) showed statistically significant differences (P < 0·05) with a noticeably lower proportion (38%) of serotype 1,3 in 3–12 months age group and higher prevalence (74%) of serotype 1,3 in the 12–24 months age group. There was no correlation between DNA type and serotype.