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Background: In aneurysms overall, a lower rate of recanalization in stent assisted coiling vs coiling alone has been observed without an increase in morbidity. This study aims to stratify and compare degree of occlusion outcome by treatment modalities. Secondarily, this study aims to stratify and compare postoperative adverse events. Methods: MEDLINE and EMBASE databases were searched. Study center were reviewed for inclusion. We performed meta-regressions, bias analysis and fail-safe N. We controlled for the quality of the studies. Results: 396 nonduplicated patients were separated into 4 groups: microsurgical, stent-assisted coiling, coiling, stent only. Stent-assisted coiling has lower rate of retreatment (17 vs 24%) and higher rehemorrhage (5% vs 3%) compared to coiling. Stent-assisted has higher rates of complete occlusion (55% vs 45%) and lower rate of residual aneurysm (15% vs 23%) compared to coiling. Comparative analyses were performed. Microsurgical remained the most morbid modality with the best rate of complete occlusion (93%) and lowest rehemorrhage (2%) and retreatment rate (5%). Conclusions: This is the first and largest meta-analysis focusing on patients treated for basilar apex aneurysm. To our knowledge, this is the first study to stratify and compare degree of occlusion per treatment modality. This study provides benchmark numbers to guide clinicians.
Callous-unemotional (CU) traits are critical to developmental, diagnostic, and clinical models of antisocial behaviors (AB). However, assessments of CU traits within large-scale longitudinal and neurobiologically focused investigations remain remarkably sparse. We sought to develop a brief measure of CU traits using items from widely administered instruments that could be linked to neuroimaging, genetic, and environmental data within already existing datasets and future studies.
Data came from a large and diverse sample (n = 4525) of youth (ages~9–11) taking part in the Adolescent Brain and Cognitive Development (ABCD) Study. Moderated nonlinear factor analysis was used to assess measurement invariance across sex, race, and age. We explored whether CU traits were distinct from other indicators of AB, investigated unique links with theoretically-relevant outcomes, and replicated findings in an independent sample.
The brief CU traits measure demonstrated strong psychometric properties and evidence of measurement invariance across sex, race, and age. On average, boys endorsed higher levels of CU traits than girls and CU traits were related to, yet distinguishable from other indicators of AB. The CU traits construct also exhibited expected associations with theoretically important outcomes. Study findings were also replicated across an independent sample of youth.
In a large, multi-site study, a brief measure of CU traits can be measured distinctly from other dimensions of AB. This measure provides the scientific community with a method to assess CU traits in the ABCD sample, as well as in other studies that may benefit from a brief assessment of CU.
Introduction: The 2015 CanMEDS framework requires all residency programs to increase their focus on Quality Improvement and Patient Safety (QIPS). We created a longitudinal (4-year), modular QIPS curriculum for FRCP emergency medicine residents at the University of Toronto (UT) using multiple educational methods. The curriculum addresses three levels of QIPS training: knowledge, practical skills at the microsystem level, and practical skills at the organization level. Aim Statement: To increase the UT FRCP emergency medicine residents absolute score on the QIKAT-R (Quality Improvement Knowledge Application Tool Revised) by 10% after the completion of the QIPS curriculum. Methods: Physicians and other healthcare professionals with QI expertise collaboratively designed and taught the curriculum. We used the QIKAT-R as the outcome measure to evaluate QI knowledge and its applicability. The QIKAT-R is a validated measure that assesses an individuals ability to decipher a QI issue within the healthcare context, and propose a change initiative to address it. The first cohort of residents completed the QIKAT-R prior to the first session in 2014 (pre) and at the completion of the curriculum in 2017 (post). Each response was anonymized and scored by physicians with QI expertise. The QIKAT-R scores and comments from course evaluations are used to make yearly iterative curriculum changes. Results: The QIPS curriculum was implemented in September 2014. All nine residents in the first cohort completed the curriculum; they demonstrated an absolute increase of 19.6% (5.3/27) in the mean QIKAT-R score (13.0 +/− 3.3 pre vs. 18.3 +/− 3.8 post, p=0.001). Of the pre-test responses, 26% were categorized as poor, 70% as good, and 4% as excellent, whereas of the post-test 11% of responses were categorized as poor, 37% as good, and 52% as excellent (p<0.001). Two iterative curriculum changes were made at the end of each academic year since 2014: (1) The time between sessions were decreased to promote knowledge retention, and (2) different PGY3 QI practical project options were provided to suit residents individual QI interests. QIKAT-R scores and resident feedback were used to evaluate the impact of the curriculum changes. Conclusion: A collaborative, modular, longitudinal QIPS curriculum for UT FRCP emergency medicine residents that met CanMEDS requirements was created using multiple educational methods. The first resident cohort that completed the curriculum demonstrated an absolute increase in QI knowledge and its applicability (as measured by the QIKAT-R) by 19.6%. Two PDSA cycles were completed to improve the curriculum with the change ideas generated from resident feedback. Ongoing challenges include limited staff availability to teach and supervise resident QI projects. Future directions include incentivising staff participation and providing mentorship for residents with a career interest in QI beyond what is offered by the curriculum.
Introduction / Innovation Concept: The 2015 CanMEDS framework requires all Canadian residency programs to increase their focus on Quality Improvement and Patient Safety (QIPS). A survey of the FRCP Emergency Medicine Residency Program Directors in Canada (63% response rate, 8/13) found that 75% (6/8) of programs have QIPS curricula with 84% (5/6) in the form of didactic lectures and 67% (4/6) as resident participation in a local project. Lectures alone do not expose learners to the practicality of conducting a QIPS project, and local resident projects often do not expose learners to the complexities of organization-wide QI initiatives. Furthermore, QI initiatives require working in interdisciplinary teams. We therefore hypothesize that an effective QIPS curriculum will require multiple education methods delivered using a multi-disciplinary lens. Methods: A collaborative longitudinal QIPS curriculum for emergency medicine residents at the University of Toronto (UT) was developed using multiple educational methods by physicians and non-medical QI specialists. The curriculum addresses three levels of QIPS training: Knowledge (lectures in PGY1 and 2), practical skills at the local clinical microsystem level (QI project in PGY3), and practical skills at the organization level (problem solving using the case method in PGY5). Curriculum, Tool, or Material: The lectures are taught by physicians involved in local and organization-wide QI projects and by those in senior management. The PGY3 residents enrol in a co-learning curriculum developed by the Department of Medicine, where residents and faculty conduct a local QI project together. The PGY5 teaching cases were created with management consultants using material from a real hospital QIPS initiative. PGY5s are taught using the case method that places the learner in the role of the organization’s manager who discusses the issues in class and proposes actions. Residents learn about the practicality of their recommendations by discussion with the management consultants, who disclose the case outcomes and review the lessons learned. Conclusion: A longitudinal QIPS curriculum for emergency medicine residents at UT was developed collaboratively. Multiple teaching methods address all three levels of QIPS training. This curriculum represents a novel use of the case method to instruct QIPS project leadership and management outside of the business school setting. Discussions with management consultants provide a different perspective of the real-life challenges of conducting QIPS initiatives.
Boiling is the most common method of household water treatment in developing countries; however, it is not always effectively practised. We conducted a randomized controlled trial among 210 households to assess the effectiveness of water pasteurization and safe-storage interventions in reducing Escherichia coli contamination of household drinking water in a water-boiling population in rural Peru. Households were randomized to receive either a safe-storage container or a safe-storage container plus water pasteurization indicator or to a control group. During a 13-week follow-up period, households that received a safe-storage container and water pasteurization indicator did not have a significantly different prevalence of stored drinking-water contamination relative to the control group [prevalence ratio (PR) 1·18, 95% confidence interval (CI) 0·92–1·52]. Similarly, receipt of a safe-storage container alone had no effect on prevalence of contamination (PR 1·02, 95% CI 0·79–1·31). Although use of water pasteurization indicators and locally available storage containers did not increase the safety of household drinking water in this study, future research could illuminate factors that facilitate the effective use of these interventions to improve water quality and reduce the risk of waterborne disease in populations that boil drinking water.
Local models are given for the singularities that can appear on the trajectories ofgeneral motions of the plane with more than two degrees of freedom. Versal unfoldings of these model singularities give rise to computer-generated pictures describing the family of trajectories arising from small deformations of the tracing point, and determine the local structure of the bifurcation curves.
To assess the impact of habitat fragmentation on tropical avian communities, we sampled lowland forest birds on six land-bridge islands and two mainland forest sites in Lake Kenyir, Peninsular Malaysia using timed point counts, hypothesizing that insectivorous birds are the worst affected guild. We used an information-theoretic approach to evaluate the effects of area, isolation, primary dietary guild (omnivore, frugivore and insectivore) and their interactions in predicting species richness, abundance and diversity. Our analysis showed that a model that considered the effects of area, dietary guild and their interaction best explained observed patterns of species richness. But a model considering both area and dietary guild best explained the variation in abundance. Notably, insectivorous birds were singled out as the dietary guild most sensitive to fragmentation, followed by frugivorous and omnivorous birds and hence provide support for our hypothesis. Assemblages of insectivorous birds were clearly depauperate on anthropogenic forest islands in Lake Kenyir and are consistent with forest fragmentation studies in the Neotropics. Given their specialized foraging ecology and diversity, conservation of intact communities of insectivorous bird guilds in Malaysia will be critical for maintaining predator–prey interactions in lowland tropical forests.
Meltwater habitats in the Darwin Glacier region, Victoria Land (80°S), were sampled in December 2007 and January 2009 to characterize their microbial and metazoan ecology, nutrient status and geochemistry. Targeted areas included terrestrial ponds of the Grant Valley, Lake Wellman, Tentacle Ridge and Diamond Hill, and supraglacial ponds and cryoconite holes of the lower Darwin Glacier. Geochemistry ranged from Na-Cl dominated terrestrial ponds to Na-HCO3 dominated, dilute supraglacial ponds and cryoconites. All showed the nitrate enrichment typical of inland ponds of Victoria Land (up to 13 g.l-1 NO3-N), with some precipitating nitratine (NaNO3) salt. Elevated pH indicated ongoing photosynthetic processes. Benthic microbial mats were thin and poorly developed, dominated by oscillatoriacean cyanobacteria. Nitrogen-fixing genera were generally absent and diatoms were rare. A large (20 μm long) Cyanothece species was the most abundant cyanobacterium in the water and in sediments of the cryoconites. DNA finger-printing identified distinct differences in cyanobacterial and bacterial community structure between the cryoconites, terrestrial ponds and ponds on glacial margins. Eleven metazoan species were identified, with rotifers being the most abundant. Pond substrate (terrestrial rock, ice-cored moraine or supraglacial ice) proved to be a more significant influence on biogeochemistry than other aspects of geography or climatic conditions.
Minority ethnic groups in the UK are reported to have a poor experience of mental health services, but comparative information is scarce.
To examine ethnic differences in patients' experience of community mental health services.
Trusts providing mental health services in England conducted surveys in 2004 and 2005 of users of community mental health services. Multiple regression was used to examine ethnic differences in responses.
About 27 000 patients responded to each of the surveys, of whom 10% were of minority ethnic origin. In the 2004 survey, age, living alone, detention and hospital admissions were stronger predictors of patient experience than ethnicity Self-reported mental health status had the strongest explanatory effect. In the 2005 survey, the main negative differences relative to the White British were for Asians.
Ethnicity had a smaller effect on patient experience than other variables. Relative to the White British, the Black group did not report negative experiences whereas the Asian group were most likely to respond negatively. However, there is a need for improvements in services for minority ethnic groups, including access to talking therapies and better recording of ethnicity.
Mark S. Edwards, San Diego Zoo, Zoological Society of San Diego,
Rongping Wei, China Conservation and Research Center for the Giant Panda,
Janet Hawes, San Diego Zoo, Zoological Society of San Diego,
Meg Sutherland-Smith, San Diego Zoo, Zoological Society of San Diego,
Chunxiang Tang, China Conservation and Research Center for the Giant Panda,
Desheng Li, China Conservation and Research Center for the Giant Panda,
Daming Hu, China Conservation and Research Center for the Giant Panda,
Guiquan Zhang, China Research and Conservation Center for the Giant Panda
Among eutherians, ursids have a significant disparity between maternal weight and neonatal weight (Leitch et al., 1959). The giant panda also produces a smaller litter mass relative to maternal body mass than, for example, the American black bear (Oftedal & Gittleman, 1989; Ramsay & Dunbrack, 1996; Zhu et al., 2001). The giant panda neonate is particularly altricial (i.e. highly dependent on parental care), requiring 24-hour care during the first weeks of life. This chapter deals with the issues and intricacies associated with the newborn giant panda cub, including hand-rearing and medical management.
NEONATAL CARE AND HAND-REARING: METHODS, RESULTS AND RECOMMENDATIONS
Indications for hand-rearing
Although maternal care is always preferred for the giant panda cub, there are situations when human care-giving is mandatory. The most obvious is maternal abandonment, which usually becomes apparent within the first five to ten minutes of birth. A female that abandons her cub will typically leave it on the ground and move away, showing little or no interest. Intervention is also required when the dam holds the cub improperly (malpositioning). Such a cub can neither nurse nor rest, often moves about excessively (in an attempt to achieve proper positioning on its own) and then can fall to the ground. A third complication is the common production of two or more cubs (mean litter size is 1.7; range 1–3) (Schaller et al., 1985).
Medulloblastoma is the most common malignant central nervous system tumour in children but, in contrast, quite rare in adults. Hemispheric, rather than midline, cerebellar medulloblastomas are more common in older children and adults. We present the unusual case of a 71-year-old man who presented with a fourth ventricular mass that proved to be a medulloblastoma.
A 71-year-old man presented with progressive balance problems, slurred speech and double vision. A CT scan of the brain revealed a hyperattenuating, partially calcified, avidly enhancing mass within the fourth ventricle. Diffusion weighted MRI showed restricted diffusion within the mass. The patient underwent a midline suboccipital craniotomy and a subtotal resection was achieved.
Histological examination showed a densely cellular neoplasm composed of small cells with a tendency towards neuroblastic rosette formation. Most cells were strongly positive for neuron-specific enolase and synaptophysin. Ultrastructurally, tumour cells showed evidence of neuronal differentiation. These findings were consistent with a classical medulloblastoma.
Adult medulloblastoma should be considered in the differential diagnosis of a partially calcified hyperattenuating mass within the fourth ventricle.
Glutamate release from photoreceptor terminals is controlled by
voltage-dependent calcium channels (VDCCs). In humans, mutations in the
Cacna1f gene, encoding the α1F subunit of VDCCs,
underlie the incomplete form of X-linked congenital stationary night
blindness (CSNB2). These mutations impair synaptic transmission from rod
and cone photoreceptors to bipolar cells. Here, we report anatomical and
functional characterizations of the retina in the nob2 (no
b-wave 2) mouse, a naturally occurring mutant caused by a null
mutation in Cacna1f. Not surprisingly, the b-waves of
both the light- and dark-adapted electroretinogram are abnormal in
nob2 mice. The outer plexiform layer (OPL) is disorganized, with
extension of ectopic neurites through the outer nuclear layer that
originate from rod bipolar and horizontal cells, but not from
hyperpolarizing bipolar cells. These ectopic neurites continue to express
mGluR6, which is frequently associated with profiles that label with the
presynaptic marker Ribeye, indicating potential points of ectopic synapse
formation. However, the morphology of the presynaptic Ribeye-positive
profiles is abnormal. While cone pedicles are present their morphology
also appears compromised. Characterizations of visual responses in retinal
ganglion cells in vivo, under photopic conditions, demonstrate
that ON-center cells have a reduced dynamic range, although their basic
center-surround organization is retained; no alteration in the responses
of OFF-center cells was evident. These results indicate that nob2
mice are a valuable model in which to explore the pathophysiological
mechanisms associated with Cacna1f mutations causing CSNB2, and
the subsequent effects on visual information processing. Further, the
nob2 mouse represents a model system in which to define the
signals that guide synapse formation and/or maintenance in the
The Jackson Laboratory, having the world's largest collection of
mouse mutant stocks and genetically diverse inbred strains, is an ideal
place to discover genetically determined eye variations and disorders. In
this paper, we list and describe mouse models for ocular research
available from Mouse Eye Mutant Resource at The Jackson Laboratory. While
screening mouse strains and stocks at The Jackson Laboratory (TJL) for
genetic mouse models of human ocular disorders, we have identified
numerous spontaneous or naturally occurring mutants. We characterized
these mutants using serial indirect ophthalmoscopy, fundus photography,
electroretinography (ERG) and histology, and performed genetic analysis
including linkage studies and gene identification. Utilizing
ophthalmoscopy, electroretinography, and histology, to date we have
discovered 109 new disorders affecting all aspects of the eye including
the lid, cornea, iris, lens, and retina, resulting in corneal disorders,
glaucoma, cataracts, and retinal degenerations. The number of known
serious or disabling eye diseases in humans is large and affects millions
of people each year. Yet research on these diseases frequently is limited
by the obvious restrictions on studying pathophysiologic processes in the
human eye. Likewise, many human ocular diseases are genetic in origin, but
appropriate families often are not readily available for genetic studies.
Mouse models of inherited ocular disease provide powerful tools for rapid
genetic analysis, characterization, and gene identification. Because of
the great similarity among mammalian genomes, these findings in mice have
direct relevance to the homologous human conditions.
Biological invasions are a major environmental concern due to their negative impacts on biodiversity and economics. We determined the population sizes and habitat-abundance relationships of the three most successful invasive bird species in Singapore: the house crow Corvus splendens, white-vented myna Acridotheres javanicus and common myna A. tristis. Estimated population sizes of the three species between February 2000 and February 2001 were between 106 000-176 000, 122 000-155 000 and 20 000-29 000, respectively. Population size of the house crow grew dramatically (>30-fold) in the last 15-16 y while that of the white-vented and common myna declined. Habitat-abundance relationships suggest that house crows are highly dependent on anthropogenic food. Their abundance was also positively related to proximity to coast. The common myna associated closely with agricultural areas while the white-vented myna probably preferred urban greenery among residential buildings. Our study shows that the three invasive bird species associated with different aspects of human-modified environment.
The effects of common variants of cholesteryl ester transfer protein (CETP) (TaqIB), hepatic lipase (HL) (−514C>T), lipoprotein lipase (LPL) (S447X) and lecithin cholesterol acyl transferase (LCAT) (S208T) on the determination of high density lipoprotein cholesterol (HDL-C) and apolipoprotein AI (apoAI) levels were examined in 2773 healthy middle-aged men participating in the second Northwick Park Heart Study. The extent of gene:gene, gene:smoking and gene:alcohol interactions were determined. For HDL-C levels, only CETP genotype was associated with significant effects (p<0·0001), with the B2 allele being associated with higher levels in both smokers and non-smokers. This interaction was significant at the lowest tertile of TG, suggesting that TG levels were rate limiting. As previously reported, CETP, LPL and HL genotypes were all associated with significant effects on apoAI levels (all p<0·01), with carriers of the rare alleles having higher levels and with no evidence of heterogeneity of effects in smokers and non-smokers. LCAT genotype was not associated with significant effects on either trait. There was no significant interaction between any of the genotypes and alcohol consumption on either HDL-C or apoAI levels. All genotypic effects were additive for HDL-C and apoAI. Environmental and TG levels explained more than 20% and 5·5% of the variance in HDL-C and apoAI, respectively. The novel aspect of this finding is that genetic variation at these loci explained in total only 2·5% of the variance in HDL-C and 1·89% of the variance in apoAI levels. Thus despite the key roles played by these enzymes in HDL metabolism, variation at these loci, at least as detected by these common genotypes, contributes minimally to the variance in HDL-C and apoAI levels in healthy men, highlighting the polygenic and multifactorial control of HDL-C.
Background. Female nurses appear to have an increased risk of suicide but the reasons are unknown.
Method. We have concluded a study of nurse suicides (N = 106) in England and Wales, including a psychological autopsy study (N = 42) and case–control comparison with living nurses (N = 84).
Results. Nearly three-quarters of the nurse suicides had previous contact with psychiatric services and almost half had been psychiatric in-patients in the past. There were particularly marked differences between the cases and controls for current psychiatric disorder (90·5% v. 7·1%, OR = 68·5), personality disorder (38·1% v. 1·2%, OR = 32), and history of deliberate self-harm (71·4% v. 2· 4%, OR = 58·5). Family background and social factors (especially concerning interpersonal relationships) also distinguished the two groups. Smoking and serious alcohol abuse were much more frequent in the suicides. There was some indication that while many of the suicides were in contact with psychiatric services, care may not have been optimal in some cases.
Conclusions. The most important strategies for suicide prevention in nurses are in prevention, detection and management of psychiatric disorders. In assessing suicide risk a history of DSH and the presence of comorbid psychiatric and personality disorders are particularly important.
Whereas some metabolites of antipsychotic drugs are psychoactive and contribute to clinical improvement, recent studies have provided evidence that certain metabolites contribute to side-effects which can be disabling enough to negate clinical improvement as regards the psychosis. The route of administration of the drug can determine the amount of metabolite produced in the body and affect how the patient feels in response to the treatment.