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Epistaxis is a common ENT presentation. The British National Formulary lists epistaxis as a common side effect of atorvastatin. This study aimed to better understand the relationship between epistaxis and atorvastatin use, and determine whether ENT doctors are aware of its side effect profile.
A retrospective analysis over 10 months identified 100 individuals who presented to hospital with epistaxis. A questionnaire of 24 ENT registrars was undertaken.
Of the 100 patients admitted with epistaxis, 27 were receiving atorvastatin and 21 simvastatin. None of the 24 ENT registrars were aware that epistaxis was a listed common side effect of atorvastatin.
There was no apparent difference in the proportion of patients admitted with epistaxis taking atorvastatin versus simvastatin. Epistaxis is an unknown side effect of atorvastatin; doctors have an obligation to be aware of the pharmaceutical literature and to consider alternatives, particularly in re-admissions cases.
Non-tuberculous mycobacterium encephalitis is rare. Since 2013, a global outbreak of Mycobacterium chimaera infection has been attributed to point-source contamination of heater cooler units used in cardiac surgery. Disseminated M. chimaera infection has presented many unique challenges, including non-specific clinical presentations with delays in diagnosis, and a high mortality rate among predominantly immunocompetent adults. Here, we describe three patients with fatal disseminated Mycobacterium chimaera infection showing initially non-specific, progressively worsening neurocognitive decline, including confusion, delirium, depression and apathy. Autopsy revealed widespread granulomatous encephalitis of the cerebrum, brain stem and spinal cord, along with granulomatous chorioretinitis. Cerebral involvement and differentiation between mycobacterial granulomas and microangiopathic changes can be assessed best on MRI with contrast enhancement. The prognosis of M. chimaera encephalitis appears to be very poor, but might be improved by increased awareness of this new syndrome and timely antimicrobial treatment.
This presentation will enable the learner to:
1.Describe the clinical, radiological and neuropathological findings of Mycobacterium chimaera encephalitis
2.Be aware of this rare form of encephalitis, and explain its diagnosis, prognosis and management
In Canada, recreational use of cannabis was legalized in October 2018. This policy change along with recent publications evaluating the efficacy of cannabis for the medical treatment of epilepsy and media awareness about its use have increased the public interest about this agent. The Canadian League Against Epilepsy Medical Therapeutics Committee, along with a multidisciplinary group of experts and Canadian Epilepsy Alliance representatives, has developed a position statement about the use of medical cannabis for epilepsy. This article addresses the current Canadian legal framework, recent publications about its efficacy and safety profile, and our understanding of the clinical issues that should be considered when contemplating cannabis use for medical purposes.
Prior research on Hodgins’ (2008) typology of offenders with schizophrenia spectrum disorders (SSD) has revealed inconsistencies in the number of subgroups and the operationalization of the concept. This study addressed these inconsistencies by applying latent class analysis (LCA) based on the most frequently explored variables in prior research. This novel case-centred methodology identified similarities and differences between the subjects contained in the sample instead of the variables explored. The LCA was performed on 71 variables taken from data on a previously unstudied sample of 370 case histories of offenders with SSD in a centre for inpatient forensic therapies in Switzerland. Results were compared with Hodgins’ theoretically postulated patient typologies and confirm three separate homogeneous classes of schizophrenic delinquents. Previous inconsistencies and differences in operationalizations of the typology of offenders with SDD to be found in the literature are discussed.
Simulation-based training has a fundamental role in medical education as it allows the learner to gain experience managing emergencies in a safe, controlled environment.
This 1-day course consisted of eight high-fidelity simulation scenarios, followed by a video-assisted debrief focusing on the technical and non-technical (communication skills, teamwork, leadership and situational awareness) aspects of managing ENT and head and neck emergencies.
Eight courses have run since June 2014. Post-course questionnaires demonstrated that candidates’ confidence scores in managing airway and head and neck emergencies increased following completion of the course (p < 0.0001).
This was the first fully immersive ENT simulation course developed in the region. The learning objectives for each scenario were mapped to the ENT Intercollegiate Surgical Curriculum Programme. Feedback from the course indicated a continued demand for this style of training, leading to its inclusion in the training calendar.
Although polyphenols inhibit glucose absorption and transport in vitro, it is uncertain whether this activity is sufficient to attenuate glycaemic response in vivo. We examined this using orange juice, which contains high levels of hesperidin. We first used a combination of in vitro assays to evaluate the potential effect of hesperidin and other orange juice components on intestinal sugar absorption and then tested whether this translated to an effect in healthy volunteers. Hesperidin attenuated transfer of 14C-labelled glucose across differentiated Caco-2/TC7 cell monolayers. The involvement of the sugar transporter GLUT2 was demonstrated by experiments carried out in the absence of Na to exclude the contribution of sodium-glucose linked transporter 1 and further explored by the use of Xenopus laevis oocytes expressing human GLUT2 or GLUT5. Fructose transport was also affected by hesperidin partly by inhibition of GLUT5, while hesperidin, even at high concentration, did not inhibit rat intestinal sucrase activity. We conducted three separate crossover interventions, each on ten healthy volunteers using orange juice with different amounts of added hesperidin and water. The biggest difference in postprandial blood glucose between orange juice and control, containing equivalent amounts of glucose, fructose, sucrose, citric acid and ascorbate, was when the juice was diluted (ΔCmax=–0·5 mm, P=0·0146). The effect was less pronounced when the juice was given at regular strength. Our data indicate that hesperidin can modulate postprandial glycaemic response of orange juice by partial inhibition of intestinal GLUT, but this depends on sugar and hesperidin concentrations.
We present observations of 50 deg2 of the Mopra carbon monoxide (CO) survey of the Southern Galactic Plane, covering Galactic longitudes l = 300–350° and latitudes |b| ⩽ 0.5°. These data have been taken at 0.6 arcmin spatial resolution and 0.1 km s−1spectral resolution, providing an unprecedented view of the molecular clouds and gas of the Southern Galactic Plane in the 109–115 GHz J = 1–0 transitions of 12CO, 13CO, C18O, and C17O.
We present a series of velocity-integrated maps, spectra, and position-velocity plots that illustrate Galactic arm structures and trace masses on the order of ~106 M⊙ deg−2, and include a preliminary catalogue of C18O clumps located between l = 330–340°. Together with the information about the noise statistics of the survey, these data can be retrieved from the Mopra CO website and the PASA data store.
The discovery of the first electromagnetic counterpart to a gravitational wave signal has generated follow-up observations by over 50 facilities world-wide, ushering in the new era of multi-messenger astronomy. In this paper, we present follow-up observations of the gravitational wave event GW170817 and its electromagnetic counterpart SSS17a/DLT17ck (IAU label AT2017gfo) by 14 Australian telescopes and partner observatories as part of Australian-based and Australian-led research programs. We report early- to late-time multi-wavelength observations, including optical imaging and spectroscopy, mid-infrared imaging, radio imaging, and searches for fast radio bursts. Our optical spectra reveal that the transient source emission cooled from approximately 6 400 K to 2 100 K over a 7-d period and produced no significant optical emission lines. The spectral profiles, cooling rate, and photometric light curves are consistent with the expected outburst and subsequent processes of a binary neutron star merger. Star formation in the host galaxy probably ceased at least a Gyr ago, although there is evidence for a galaxy merger. Binary pulsars with short (100 Myr) decay times are therefore unlikely progenitors, but pulsars like PSR B1534+12 with its 2.7 Gyr coalescence time could produce such a merger. The displacement (~2.2 kpc) of the binary star system from the centre of the main galaxy is not unusual for stars in the host galaxy or stars originating in the merging galaxy, and therefore any constraints on the kick velocity imparted to the progenitor are poor.
HESS J1614–518 and HESS J1616–508 are two tera-electron volt γ-ray sources that are not firmly associated with any known counterparts at other wavelengths. We investigate the distribution of interstellar medium towards the tera-electron volt γ-ray sources using results from a 7-mm-wavelength Mopra study, the Mopra Southern Galactic Plane CO Survey, the Millimetre Astronomer’s Legacy Team-45 GHz survey and [C i] data from the HEAT telescope. Data in the CO(1–0) transition lines reveal diffuse gas overlapping the two tera-electron volt sources at several velocities along the line of sight, while observations in the CS(1–0) transition line reveal several interesting dense gas features. To account for the diffuse atomic gas, archival H i data was taken from the Southern Galactic Plane Survey. The observations reveal gas components with masses ~103 to 105 M⊙ and with densities ~102 to 103 cm−3 overlapping the two tera-electron volt sources. Several origin scenarios potentially associated with the tera-electron volt γ-ray sources are discussed in light of the distribution of the local interstellar medium. We find no strong convincing evidence linking any counterpart with HESS J1614–518 or HESS J1616–508.
Background: Morphometry and connectivity studies targeting the thalamus have revealed specific patterns of atrophy and deafferentiation in patients with temporal lobe epilepsy (TLE). We used probabilistic tractography to investigate thalamic connectivity with respect to duration of epilepsy and surgical outcomes in TLE. Methods: Patients (N=20) with drug-resistant TLE (10 short duration (<15 years), 10 long duration (>15 years)) were scanned with multi-parametric 3T MRI and compared with 34 healthy controls. The Harvard-Oxford atlas was modified to create 14 target regions in the temporal lobes. Probabilistic tractography (FSL) was used to delineate thalamic sub-regions most connected to each target. The volume, mean T1, T2, FA and MD of each thalamic sub-region was quantified. Surgical success was quantified using Engel outcome scores. Results: Significant decreases in thalamic connected volumes to the hippocampus in patients with longer duration of TLE were revealed. Likewise, when stratified based on surgical success, significant differences in diffusion metrics to the hippocampus, parahippocampal gyrus, and temporal neocortex were found. Significant differences did not withstand false discovery rate (FDR) correction. Conclusions: These findings suggest ongoing connectivity changes dependent on epilepsy duration and promote further investigation into the use of thalamic connectivity data as biomarkers for predicting surgical outcomes in TLE patients.
Background: The goal of a brain tumour operation is maximal safe resection. No widely used guidelines for the use of functional magnetic resonance imaging (fMRI) in these patients currently exist. In this study we are trying to determine if and how Canadian neurosurgeons use fMRI in the management of patients with low grade glioma (LGG). Methods: A 15-25 minute survey was created using an online survey tool. In Part One of the study the survey was distributed to neurosurgery consultant and resident staff at the London Health Sciences Centre (LHSC). In Part Two of the study the survey is being distributed to members of the Canadian Neurosurgical Society. The survey consists of two sections - background and case-based decision making. Results: There were six surveys from the LHSC staff. On average respondents indicated that they obtain fMRI for 9% of LGG patients, though 67% indicated that they were comfortable ordering and interpreting fMRI studies. In the case-based section, fMRI data did not tend to affect respondents’ preferred treatment, confidence in their treatment, or their predicted risk of surgical treatment. Conclusions: In this limited survey of LHSC neurosurgical staff there was no regular use of fMRI in LGG patients. We await the results of a national survey of Canadian neurosurgeons.
Introduction: Analyzing the charts of patients who have a return visit to an emergency department (ED) requiring hospital admission (termed ‘RV’) is an efficient way to identify adverse events (AEs). Investigating these AEs can inform efforts to improve the quality of care provided. The ED RV Quality Program (RVQP) is a new initiative supported by Ontario’s Ministry of Health and Long-Term Care and managed by Health Quality Ontario. It aims to promote a culture of continuous quality improvement through routine audit/investigation of RVs. Methods: The provincial program is mandatory for high-volume EDs and requires auditing of some 72-hour RVs and all 7-day RVs involving ‘sentinel diagnoses’ (subarachnoid hemorrhage [SAH], acute myocardial infarction [AMI], or pediatric sepsis [PS]). A standardized audit template is followed that includes assessment of the type/severity and underlying causes of AEs, and potential actions for improvement. Results: 73 high-volume EDs and 16 smaller EDs (collectively receiving 90% of all ED visits in Ontario) are participating in the program. Nine months’ data have been released to date, comprising 33,956 RVs (1.05% of 3,235,751 ED visits). Of these, 233 RVs (0.69%) were for a sentinel diagnosis (SAH=11, AMI=191, PS=31). The most common presenting complaint on the index visit was abdominal pain (18%). The most common discharge diagnosis following RV admission was acute appendicitis (3.8%). Conclusion: The ED RVQP aims to improve the quality of care provided in Ontario’s EDs by requiring hospitals to conduct audits of RVs and plan actions for improvement when quality gaps are identified. Participating hospitals have completed hundreds of audits to date.
The development of an economic capital model requires a decision to be made regarding how to aggregate capital requirements for the individual risk factors while taking into account the effects of diversification. Under the Individual Capital Adequacy Standards framework, UK life insurers have commonly adopted a correlation matrix approach due to its simplicity and ease in communication to the stakeholders involved, adjusting the result, where appropriate, to allow for non-linear interactions. The regulatory requirements of Solvency II have been one of the principal drivers leading to an increased use of more sophisticated aggregation techniques in economic capital models. This paper focusses on a simulation-based approach to the aggregation of capital requirements using copulas and proxy models. It describes the practical challenges in parameterising a copula including how allowance may be made for tail dependence. It also covers the challenges associated with fitting and validating a proxy model. In particular, the paper outlines how insurers could test, communicate and justify the choices made through the use of some examples.
The present study addresses the reaction zone structure and burning mechanism of unstable detonations. Experiments investigated mainly two-dimensional methane–oxygen cellular detonations in a thin channel geometry. The sufficiently high temporal resolution permitted the determination of the probability density function of the shock distribution, a power law with an exponent of
, and the burning rate of unreacted pockets from their edges – through surface turbulent flames with a speed approximately 3–7 times larger than the laminar one at the local conditions. Numerical simulations were performed using a novel large-eddy simulation method where the reactions due to both autoignition and turbulent transport were treated exactly at the subgrid scale in a reaction–diffusion formulation. The model is an extension of Kerstein and Menon’s linear eddy model for large-eddy simulation to treat flows with shock waves and rapid gas-dynamic transients. The two-dimensional simulations recovered well the amplification of the laminar flame speed due to the turbulence generated mainly by the shear layers originating from the triple points and subsequent Richtmyer–Meshkov instability associated with the internal pressure waves. The simulations clarified how the level of turbulence generated controlled the burning rate of the pockets, the hydrodynamic thickness of the wave, the cellular structure and its distribution. Three-dimensional simulations were found to be in general good agreement with the two-dimensional ones, in that the subgrid-scale model captured the ensuing turbulent burning once the scales associated with the cellular dynamics, where turbulent kinetic energy is injected, are well resolved.
To identify the common causal beliefs of mental illness in a multi-ethnic Southeast Asian community and describe the sociodemographic associations to said beliefs. The factor structure to the causal beliefs scale is explored. The causal beliefs relating to five different mental illnesses (alcohol abuse, depression, obsessive-compulsive disorder (OCD), dementia and schizophrenia) and desire for social distance are also investigated.
Data from 3006 participants from a nationwide vignette-based study on mental health literacy were analysed using factor analysis and multiple logistic regression to address the aims. Participants answered questions related to sociodemographic information, causal beliefs of mental illness and their desire for social distance towards those with mental illness.
Physical causes, psychosocial causes and personality causes were endorsed by the sample. Sociodemographic differences including ethnic, gender and age differences in causal beliefs were found in the sample. Differences in causal beliefs were shown across different mental illness vignettes though psychosocial causes was the most highly attributed cause across vignettes (endorsed by 97.9% of respondents), followed by personality causes (83.5%) and last, physical causes (37%). Physical causes were more likely to be endorsed for OCD, depression and schizophrenia. Psychosocial causes were less often endorsed for OCD. Personality causes were less endorsed for dementia but more associated with depression.
The factor structure of the causal beliefs scale is not entirely the same as that found in previous research. Further research on the causal beliefs endorsed by Southeast Asian communities should be conducted to investigate other potential causes such as biogenetic factors and spiritual/supernatural causes. Mental health awareness campaigns should address causes of mental illness as a topic. Lay beliefs in the different causes must be acknowledged and it would be beneficial for the public to be informed of the causes of some of the most common mental illnesses in order to encourage help-seeking and treatment compliance.
Though sleep disturbances are common among psychiatric patients, some patients may trivialize their problem and not discuss it with their doctors. This study thus aimed to assess patient profile that is associated with help seeking for sleep problems among psychiatric patients.
Outpatients from a tertiary psychiatric hospital were recruited for this study (n = 400). The pittsburgh sleep quality index was administered to identify cases of probable insomnia, and daytime impairment due to sleep disturbances was recorded. Participants were asked if they have ever consulted a doctor or any health professionals for their sleep problems. Sociodemographic information was recorded and clinical profile was obtained from the patient's medical records. Multivariate logistic regression was used to examine correlates of help-seeking behaviour among patients with probable insomnia.
275 cases of probable insomnia were identified. Among this group of patients, 38.9% had never sought help for their sleep problems. Participants who were single were less likely to seek help as compared to those who were widowed/separated/divorced (OR= 0.319, P = 0.023). Having a comorbid psychiatric condition was independently associated with increased odds of help seeking (OR= 1.952, P = 0.027). Participants who perceived greater daytime impairment due to sleep problems were more likely to seek help (OR= 1.465, P = 0.007).
The majority of psychiatry patients with sleep problems sought professional help, though there remained a substantial group that did not do so. There is a need to educate and create awareness of potential sleep problems among psychiatric patients, and to inform them of the availability of treatment.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Leptospirosis is a zoonotic disease that the pathogen can be transmitted to humans through the excretions of infected animals. In the Republic of Korea, the Livestock Manure Control Act was enforced in September 2007 to improve underground water hygiene. The objective of this study was to evaluate the impact of Livestock Manure Control Policy on the incidence and the trend of human leptospirosis. An interrupted time series analysis using the monthly incidence of leptospirosis was conducted based on data derived from the Korean National Surveillance System between January 1999 and January 2015. We used a Spearman correlation method to compare the level of leptospirosis incidence decrease between the metropolitan cities and rural provinces. The annual incidence of leptospirosis in South Korea decreased by 33% after policy enforcement of the policy. A significant change in the slope of human leptospirosis cases was observed after the policy enforcement (β = −0·09, P < 0·001). Moreover, we detected a clear association between the size of the rice paddy fields and the decrease in leptospirosis incidence in provinces (r = 0·817, P = 0·01). This study shows that the Livestock Manure Control Policy had significantly reduced human leptospirosis incidence in the Republic of Korea, in particular, in rural regions.
Pertussis epidemics have displayed substantial spatial heterogeneity in countries with high socioeconomic conditions and high vaccine coverage. This study aims to investigate the relationship between pertussis risk and socio-environmental factors on the spatio-temporal variation underlying pertussis infection. We obtained daily case numbers of pertussis notifications from Queensland Health, Australia by postal area, for the period January 2006 to December 2012. A Bayesian spatio-temporal model was used to quantify the relationship between monthly pertussis incidence and socio-environmental factors. The socio-environmental factors included monthly mean minimum temperature (MIT), monthly mean vapour pressure (VAP), Queensland school calendar pattern (SCP), and socioeconomic index for area (SEIFA). An increase in pertussis incidence was observed from 2006 to 2010 and a slight decrease from 2011 to 2012. Spatial analyses showed pertussis incidence across Queensland postal area to be low and more spatially homogeneous during 2006–2008; incidence was higher and more spatially heterogeneous after 2009. The results also showed that the average decrease in monthly pertussis incidence was 3·1% [95% credible interval (CrI) 1·3–4·8] for each 1 °C increase in monthly MIT, while average increase in monthly pertussis incidences were 6·2% (95% CrI 0·4–12·4) and 2% (95% CrI 1–3) for SCP periods and for each 10-unit increase in SEIFA, respectively. This study demonstrated that pertussis transmission is significantly associated with MIT, SEIFA, and SCP. Mapping derived from this work highlights the potential for future investigation and areas for focusing future control strategies.
Expert judgement is frequently used within general insurance. It tends to be a method of last resort and used where data is sparse, non-existent or non-applicable to the problem under consideration. Whilst such judgements can significantly influence the end results, their quality is highly variable. The use of the term “expert judgement” itself can lend a generous impression of credibility to what may be a little more than a guess. Despite the increased emphasis placed on the importance of robust expert judgements in regulation, actuarial research to date has focussed on the more technical or data-driven methods, with less emphasis on how to use and incorporate softer information or how best to elicit judgements from others in a way that reduces cognitive biases. This paper highlights the research that the Getting Better Judgement Working Party has conducted in this area. Specifically, it covers the variable quality of expert judgement, both within and outside the regulatory context, and presents methods that may be applied to improve its formation. The aim of this paper is to arm the insurance practitioner with tools to distinguish between low-quality and high-quality judgements and improve the robustness of judgements accordingly, particularly for highly material circumstances.