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In their chapter, Bach and Presnall-Shvorin (this volume) introduce guidelines for incorporating empirically-driven trait models of personality pathology, codified in the DSM-5 and ICD-11, into therapeutic practice. Though the authors of this commentary are supportive of the effort to bridge research with clinical practice, they suggest that a mechanistic model which accounts for personality processes underlying descriptive traits could offer greater precision than traits alone. Furthermore, they argue that clinical dysfunction can only be meaningfully defined and treated with an understanding of dynamic, contextualized aspects of personality. To illustrate how a mechanistic model could complement and extend Bach and Presnall’s recommendations, the authors present a case conceptualization using cybernetic theory. Finally, they review how idiographic data gleaned from ambulatory assessment methods provide insight into pathological processes ideal for therapeutic intervention. To achieve a generalizable approach flexible enough to adapt to the individual, they encourage the development of treatment models that go beyond traits to mechanistically link stable and dynamic personality features into a unified framework.
Improving the quality of care on psychiatric inpatient wards has been a major focus in recent mental health policy, a recurrent criticism being that contact between staff and patients is limited in time and therapeutic value. Change is unlikely to be achieved without recruitment and retention of a high quality and well-motivated work force.
The NHS commissioned national inpatient mental health staff morale study is intended to inform service planning and policy by delivering evidence on the morale of the inpatient mental health workforce and the clinical, organisational, architectural and human resources factors that influence it.
100 wards in 17 area ‘Trusts’ are participating in the study, in addition to 40 community teams. The study will take place over two years, and has 6 modules:
1. A quantitative questionnaire for all staff in participating wards and
2. A comparison group in 20 community mental health teams and 20 crisis teams.
3. Case studies of 10 wards scoring in the top and bottom quartile for indicators of morale.
4. Repeated questionnaires for 20 wards in the second year to investigate how morale changes over time.
5. Staff who leave the wards in the course of the first year will be asked their reasons for leaving.
6. Links between rates of staff sickness and morale will be investigated.
Questionnaires have been distributed to 3,500 staff with a response rate of 65%, results from which will be presented in 2009.
Evidence suggests that the subjective experience of AVHs cannot be explained by any of the existing cognitive models, highlighting the obvious need to properly investigate the actual, lived experience of AVHs, and derive models/theories that fit the complexity of this.
Via phenomenological interviews and ethnographic diary methods, we aim to gain a deeper insight into the experience of AVHs.
To explore the phenomenological quality of AVHs, as they happen/reveal themselves to consciousness,   without relying on existing suppositions.
Participants with First Episode Psychosis were recruited from the Birmingham Early Intervention Service (EIS), BSMHFT. In-depth 'walking interviews' were carried out with each participant, together with standardised assessment measures of voices. Prior to interviews, participants were asked to complete a dairy and take photographs, further capturing aspects of their AVH experiences.
20 participants have completed interviews to date. Emerging themes cover the form and quality of voices (i.e. as being separate to self, imposing, compelling etc.), and participants' understanding and management of these experiences.
Authentic descriptions gleaned from participants have the potential to increase our understanding of the relationship between the phenomenology and neurobiology of AVHs and, in turn, the experience as a whole.
Neurobiological models of auditory verbal hallucination (AVH) have been advanced by symptom capture functional magnetic resonance imaging (fMRI), where participants self-report hallucinations during scanning. To date, regions implicated are those involved with language, memory and emotion. However, previous studies focus on chronic schizophrenia, thus are limited by factors, such as medication use and illness duration. Studies also lack detailed phenomenological descriptions of AVHs. This study investigated the neural correlates of AVHs in patients with first episode psychosis (FEP) using symptom capture fMRI with a rich description of AVHs. We hypothesised that intrusive AVHs would be associated with dysfunctional salience network activity.
Sixteen FEP patients with frequent AVH completed four psychometrically validated tools to provide an objective measure of the nature of their AVHs. They then underwent fMRI symptom capture, utilising general linear models analysis to compare activity during AVH to the resting brain.
Symptom capture of AVH was achieved in nine patients who reported intrusive, malevolent and uncontrollable AVHs. Significant activity in the right insula and superior temporal gyrus (cluster size 141 mm3), and the left parahippocampal and lingual gyri (cluster size 121 mm3), P < 0.05 FDR corrected, were recorded during the experience of AVHs.
These results suggest salience network dysfunction (in the right insula) together with memory and language processing area activation in intrusive, malevolent AVHs in FEP. This finding concurs with others from chronic schizophrenia, suggesting these processes are intrinsic to psychosis itself and not related to length of illness or prolonged exposure to antipsychotic medication.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Environmental information from place-names has largely been overlooked by geoarchaeologists and fluvial geomorphologists in analyses of the depositional histories of rivers and floodplains. Here, new flood chronologies for the rivers Teme, Severn, and Wye are presented, modelled from stable river sections excavated at Broadwas, Buildwas, and Rotherwas. These are connected by the Old English term *wæsse, interpreted as ‘land by a meandering river which floods and drains quickly’. The results reveal that, in all three places, flooding during the early medieval period occurred more frequently between AD 350–700 than between AD 700–1100, but that over time each river's flooding regime became more complex including high magnitude single events. In the sampled locations, the fluvial dynamics of localized flood events had much in common, and almost certainly differed in nature from other sections of their rivers, refining our understanding of the precise nature of flooding which their names sought to communicate. This study shows how the toponymic record can be helpful in the long-term reconstruction of historic river activity and for our understanding of past human perceptions of riverine environments.
We conducted a systematic review and network meta-analysis to determine the comparative efficacy of antibiotics used to control bovine respiratory disease (BRD) in beef cattle on feedlots. The information sources for the review were: MEDLINE®, MEDLINE In-Process and MEDLINE® Daily, AGRICOLA, Epub Ahead of Print, Cambridge Agricultural and Biological Index, Science Citation Index, Conference Proceedings Citation Index – Science, the Proceedings of the American Association of Bovine Practitioners, World Buiatrics Conference, and the United States Food and Drug Administration Freedom of Information New Animal Drug Applications summaries. The eligible population was weaned beef cattle raised in intensive systems. The interventions of interest were injectable antibiotics used at the time the cattle arrived at the feedlot. The outcome of interest was the diagnosis of BRD within 45 days of arrival at the feedlot. The network meta-analysis included data from 46 studies and 167 study arms identified in the review. The results suggest that macrolides are the most effective antibiotics for the reduction of BRD incidence. Injectable oxytetracycline effectively controlled BRD compared with no antibiotics; however, it was less effective than macrolide treatment. Because oxytetracycline is already commonly used to prevent, control, and treat BRD in groups of feedlot cattle, the use of injectable oxytetracycline for BRD control might have advantages from an antibiotic stewardship perspective.
Vaccination against putative causal organisms is a frequently used and preferred approach to controlling bovine respiratory disease complex (BRD) because it reduces the need for antibiotic use. Because approximately 90% of feedlots use and 90% of beef cattle receive vaccines in the USA, information about their comparative efficacy would be useful for selecting a vaccine. We conducted a systematic review and network meta-analysis of studies assessing the comparative efficacy of vaccines to control BRD when administered to beef cattle at or near their arrival at the feedlot. We searched MEDLINE, MEDLINE In-Process, MEDLINE Daily Epub Ahead of Print, AGRICOLA, Cambridge Agricultural and Biological Index, Science Citation Index, and Conference Proceedings Citation Index – Science and hand-searched the conference proceedings of the American Association of Bovine Practitioners and World Buiatrics Congress. We found 53 studies that reported BRD morbidity within 45 days of feedlot arrival. The largest connected network of studies, which involved 17 vaccine protocols from 14 studies, was included in the meta-analysis. Consistent with previous reviews, we found little compelling evidence that vaccines used at or near arrival at the feedlot reduce the incidence of BRD diagnosis.
The separation dimension of a graph G is the minimum positive integer d for which there is an embedding of G into ℝd, such that every pair of disjoint edges are separated by some axis-parallel hyperplane. We prove a conjecture of Alon et al. [SIAM J. Discrete Math. 2015] by showing that every graph with maximum degree Δ has separation dimension less than 20Δ, which is best possible up to a constant factor. We also prove that graphs with separation dimension 3 have bounded average degree and bounded chromatic number, partially resolving an open problem by Alon et al. [J. Graph Theory 2018].
In the 1990s criteria were developed to detect individuals at high and imminent risk of developing a psychotic disorder. These are known as the at risk mental state, ultra high risk or clinical high risk criteria. Individuals meeting these criteria are symptomatic and help-seeking. Services for such individuals are now found worldwide. Recently Psychological Medicine published two articles that criticise these services and suggest that they should be dismantled or restructured. One paper also provides recommendations on how ARMS services should be operate.
In this paper we draw on the existing literature in the field and present the perspective of some ARMS clinicians and researchers.
Many of the critics' arguments are refuted. Most of the recommendations included in the Moritz et al. paper are already occurring.
ARMS services provide management of current problems, treatment to reduce risk of onset of psychotic disorder and monitoring of mental state, including attenuated psychotic symptoms. These symptoms are associated with a range of poor outcomes. It is important to assess them and track their trajectory over time. A new approach to detection of ARMS individuals can be considered that harnesses broad youth mental health services, such as headspace in Australia, Jigsaw in Ireland and ACCESS Open Minds in Canada. Attention should also be paid to the physical health of ARMS individuals. Far from needing to be dismantled we feel that the ARMS approach has much to offer to improve the health of young people.
The almost universally-occurring aggregated distributions of helminth burdens in host populations have major significance for parasite population ecology and evolutionary biology, but the mechanisms generating heterogeneity remain poorly understood. For the direct life cycle monogenean Discocotyle sagittata infecting rainbow trout, Oncorhynchus mykiss, variables potentially influencing aggregation can be analysed individually. This study was based at a fish farm where every host individual becomes infected by D. sagittata during each annual transmission period. Worm burdens were examined in one trout population maintained in isolation for 9 years, exposed to self-contained transmission. After this year-on-year recruitment, prevalence was 100% with intensities 10–2628, mean 576, worms per host. Parasite distribution, amongst hosts with the same age and environmental experience, was highly aggregated with variance to mean ratio 834 and negative binomial parameter, k, 0.64. The most heavily infected 20% of fish carried around 80% of the total adult parasite population. Aggregation develops within the first weeks post-infection; hosts typically carried intensities of successive age-specific cohorts that were consistent for that individual, such that heavily-infected individuals carried high numbers of all parasite age classes. Results suggest that host factors alone, operating post-infection, are sufficient to generate strongly overdispersed parasite distributions, rather than heterogeneity in exposure and initial invasion.
Despite knowing for many decades that depressive psychopathology is common in first-episode schizophrenia spectrum disorders (FES), there is limited knowledge regarding the extent and nature of such psychopathology (degree of comorbidity, caseness, severity) and its demographic, clinical, functional and treatment correlates. This study aimed to determine the pooled prevalence of depressive disorder and caseness, and the pooled mean severity of depressive symptoms, as well as the demographic, illness, functional and treatment correlates of depressive psychopathology in FES.
This systematic review, meta-analysis and meta-regression was prospectively registered (CRD42018084856) and conducted in accordance with PRISMA and MOOSE guidelines.
Forty studies comprising 4041 participants were included. The pooled prevalence of depressive disorder and caseness was 26.0% (seven samples, N = 855, 95% CI 22.1–30.3) and 43.9% (11 samples, N = 1312, 95% CI 30.3–58.4), respectively. The pooled mean percentage of maximum depressive symptom severity was 25.1 (38 samples, N = 3180, 95% CI 21.49–28.68). Correlates of depressive psychopathology were also found.
At least one-quarter of individuals with FES will experience, and therefore require treatment for, a full-threshold depressive disorder. Nearly half will experience levels of depressive symptoms that are severe enough to warrant diagnostic investigation and therefore clinical intervention – regardless of whether they actually fulfil diagnostic criteria for a depressive disorder. Depressive psychopathology is prominent in FES, manifesting not only as superimposed comorbidity, but also as an inextricable symptom domain.
Direct numerical simulations (DNS) are performed in a triply periodic unit cell of a face-centred cubic (FCC) lattice covering the unsteady inertial, to fully turbulent, flow regimes. The DNS data are used to quantify the flow topology, integral scales, turbulent kinetic energy (TKE) transport and anisotropy distribution in the tortuous geometry. Several unique flow features are observed within this low porosity configuration, where the mean flow undergoes strong acceleration and deceleration regions with presence of three-dimensional helical motions, weak wake-like structures behind spheres, stagnation and jet-impingement-like flows together with merging and spreading jets in the main pore space. The jet-impingement and weak wake-like flow structures give rise to regions with negative total TKE production. Unlike flows in complex shaped ducts, the turbulence intensity levels in the cross-stream directions are found to be larger than those in the streamwise direction. Furthermore, due to the compact nature and confined geometry of the FCC packing, the turbulent integral length scales are estimated to be less than 10 % of the bead diameter even for the lowest Reynolds number studied, indicating the absence of macroscale turbulence structures for this configuration. This finding suggests that even for the highly anisotropic flow within the pore, the upscaled flow statistics are captured well by the representative volumes defined by the unit cell.
Introduction: There is increasing evidence supporting ultrasonography for the determination of optimal chest compression location during cardiac arrest. Radiological studies have demonstrated that in up to 1/3 of patients the aortic root or outflow tract is being compressed during standard CPR. Out-of-hospital-cardiac-arrests (OHCA) could benefit from cardiac localization, undertaken with scaled-down ultrasound equipment by which the largest fluid filled structure in the chest (the heart) is identified to guide optimal compression location. We intend to evaluate 1) where the left ventricle is in supine patients, 2) the accuracy and precision as well as 3) the feasibility and reliability of cardiac localization with a scaled down ultrasound device (bladder scanners). Methods: We are recruiting men and women over the age of 40. The scanning protocol involves using a bladder scanner on a 15-point grid over the subject's left chest and parasternal, midclavicular, and anterior axillary intercostal spaces 3-7. Detected volumes will be recorded, with the presumption that the intercostal space with the largest measured volume is centered over the heart. Echocardiography will then be used to confirm the bladder scanner accuracy and to better describe the patient's internal chest anatomy. Having assessed procedural feasibility on 3 pilot subjects, we are now recruiting 100 participants, with planned interim analysis at 50 participants for sample size reassessment. Maximal volume location frequencies from the echocardiograms will be described and assessed for variation utilizing the goodness-of-fit test. The proportion of agreement across the two modalities regarding the maximal volume location will also be examined. Results: Among the 3 volunteers (pilot study), the scanner identified fluid in 4-8 of 15 intercostal spaces. In each of the three pilot study patients, the maximal volume identified by the bladder scanner was found to be at the parasternal location of the 6th intercostal space. This was also the location of the mid left ventricular diameter on echocardiography. Conclusion: Our literature review and pilot study data support the premise that lay persons and emergency medical personnel may improve compressions (and thus outcomes) during OHCA by using a scaled-down ultrasound to identify the location of optimal compression. We are currently enrolling patients in our study.
Innovation Concept: The fairness of the Canadian Residency Matching Service (CaRMS) selection process has been called into question by rising rates of unmatched medical students and reports of bias and subjectivity. We outline how the University of Saskatchewan Royal College emergency medicine program evaluates CaRMS applications in a standardized, rigorous, equitable and defensible manner. Methods: Our CaRMS applicant evaluation methods were first utilized in the 2017 CaRMS cycle, based on published Best Practices, and have been refined yearly to ensure validity, standardization, defensibility, rigour, and to improve the speed and flow of data processing. To determine the reliability of the total application scores for each rater, single measures intraclass correlation coefficients (ICCs) were calculated using a random effects model in 2017 and 2018. Curriculum, Tool or Material: A secure, online spreadsheet was created that includes applicant names, reviewer assignments, data entry boxes, and formulas. Each file reviewer entered data in a dedicated sheet within the document. Each application was reviewed by two staff physicians and two to four residents. File reviewers used a standardized, criterion-based scoring rubric for each application component. The file score for each reviewer-applicant pair was converted into a z-score based on each reviewer's distribution of scores. Z-scores of all reviewers for a single applicant were then combined by weighted average, with the group of staff and group of residents each being weighted to represent half of the final file score. The ICC for the total raw scores improved from 0.38 (poor) in 2017 to 0.52 (moderate) in 2018. The data from each reviewer was amalgamated into a master sheet where applicants were sorted by final file score and heat-mapped to offer a visual aid regarding differences in ratings. Conclusion: Our innovation uses heat-mapped and formula-populated spreadsheets, scoring rubrics, and z-scores to normalize variation in scoring trends between reviewers. We believe this approach provides a rigorous, defensible, and reproducible process by which Canadian residency programs can appraise applicants and create a rank order list.
An (improper) graph colouring has defect d if each monochromatic subgraph has maximum degree at most d, and has clustering c if each monochromatic component has at most c vertices. This paper studies defective and clustered list-colourings for graphs with given maximum average degree. We prove that every graph with maximum average degree less than (2d+2)/(d+2)k is k-choosable with defect d. This improves upon a similar result by Havet and Sereni (J. Graph Theory, 2006). For clustered choosability of graphs with maximum average degree m, no (1-ɛ)m bound on the number of colours was previously known. The above result with d=1 solves this problem. It implies that every graph with maximum average degree m is
-choosable with clustering 2. This extends a result of Kopreski and Yu (Discrete Math., 2017) to the setting of choosability. We then prove two results about clustered choosability that explore the trade-off between the number of colours and the clustering. In particular, we prove that every graph with maximum average degree m is
-choosable with clustering 9, and is
-choosable with clustering O(m). As an example, the later result implies that every biplanar graph is 8-choosable with bounded clustering. This is the best known result for the clustered version of the earth–moon problem. The results extend to the setting where we only consider the maximum average degree of subgraphs with at least some number of vertices. Several applications are presented.
Unlike for many other respiratory infections, the seasonality of pertussis is not well understood. While evidence of seasonal fluctuations in pertussis incidence has been noted in some countries, there have been conflicting findings including in the context of Australia. We investigated this issue by analysing the seasonality of pertussis notifications in Australia using monthly data from January 1991 to December 2016. Data were made available for all states and territories in Australia except for the Australian Capital Territory and were stratified into age groups. Using a time-series decomposition approach, we formulated a generalised additive model where seasonality is expressed using cosinor terms to estimate the amplitude and peak timing of pertussis notifications in Australia. We also compared these characteristics across different jurisdictions and age groups. We found evidence that pertussis notifications exhibit seasonality, with peaks observed during the spring and summer months (November–January) in Australia and across different states and territories. During peak months, notifications are expected to increase by about 15% compared with the yearly average. Peak notifications for children <5 years occurred 1–2 months later than the general population, which provides support to the theory that older household members remain an important source of pertussis infection for younger children. In addition, our results provide a more comprehensive spatial picture of seasonality in Australia, a feature lacking in previous studies. Finally, our findings suggest that seasonal forcing may be useful to consider in future population transmission models of pertussis.
Community-acquired pneumonia (CAP) results in substantial numbers of hospitalisations and deaths in older adults. There are known lifestyle and medical risk factors for pneumococcal disease but the magnitude of the additional risk is not well quantified in Australia. We used a large population-based prospective cohort study of older adults in the state of New South Wales (45 and Up Study) linked to cause-specific hospitalisations, disease notifications and death registrations from 2006 to 2015. We estimated the age-specific incidence of CAP hospitalisation (ICD-10 J12-18), invasive pneumococcal disease (IPD) notification and presumptive non-invasive pneumococcal CAP hospitalisation (J13 + J18.1, excluding IPD), comparing those with at least one risk factor to those with no risk factors. The hospitalised case-fatality rate (CFR) included deaths in a 30-day window after hospitalisation. Among 266 951 participants followed for 1 850 000 person-years there were 8747 first hospitalisations for CAP, 157 IPD notifications and 305 non-invasive pneumococcal CAP hospitalisations. In persons 65–84 years, 54.7% had at least one identified risk factor, increasing to 57.0% in those ⩾85 years. The incidence of CAP hospitalisation in those ⩾65 years with at least one risk factor was twofold higher than in those without risk factors, 1091/100 000 (95% confidence interval (CI) 1060–1122) compared with 522/100 000 (95% CI 501–545) and IPD in equivalent groups was almost threefold higher (18.40/100 000 (95% CI 14.61–22.87) vs. 6.82/100 000 (95% CI 4.56–9.79)). The CFR increased with age but there were limited difference by risk status, except in those aged 45 to 64 years. Adults ⩾65 years with at least one risk factor have much higher rates of CAP and IPD suggesting that additional risk factor-based vaccination strategies may be cost-effective.
To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices.
Retrospective before-and-after study.
A 1,250-bed academic tertiary-care referral center.
Hospitalized adults who had ≥1 urine culture performed during their stay.
The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends.
During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05).
Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.