To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Addictions are challenging health and social problems that need to be addressed to preserve and promote good mental health and ensure that individuals within society lead healthy and productive lives. Tackling addictions is complex and requires communities, public health, specialist services, and local and national government to act in unison and implement evidence-based interventions. This editorial raises systemic issues that need attention and proposes a range of systemic options.
Declaration of interest
K.S.B. is Editor-in-Chief of the British Journal of Psychiatry. The other authors declare no conflict of interest.
Background: There are few published reports on the safety and efficacy of stereoelectroencephalography (SEEG) in the presurgical evaluation of pediatric drug-resistant epilepsy. Our objective was to describe institutional experience with pediatric SEEG in terms of (1) insertional complications, (2) identification of the epileptogenic zone and (3) seizure outcome following SEEG-tailored resections. Methods: Retrospective review of 29 patients pediatric drug resistant epilepsy patients who underwent presurgical SEEG between 2005 – 2018. Results: 29 pediatric SEEG patients (15 male; 12.4 ± 4.6 years old) were included in this study with mean follow-up of 6.0 ± 4.1 years. SEEG-related complications occurred in 1/29 (3%)—neurogenic pulmonary edema. A total of 190 multi-contact electrodes (mean of 7.0 ± 2.5per patient) were implanted across 30 insertions which captured 437 electrographic seizures (mean 17.5 ± 27.6 per patient). The most common rationale for SEEG was normal MRI with surface EEG that failed to identify the EZ (16/29; 55%). SEEG-tailored resections were performed in 24/29 (83%). Engel I outcome was achieved following resections in 19/24 cases (79%) with 5.9 ± 4.0 years of post-operative follow-up. Conclusions: Stereoelectroencephalography in presurgical evaluation of pediatric drug-resistant epilepsy is a safe and effective way to identify the epileptogenic zone permitting SEEG-tailored resection.
Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.
Objective: To determine the relationship between intraoperative flash visual evoked potential (FVEP) monitoring and visual function. Methods: Intraoperative FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex (Oz) after flashing red light stimulation delivered by Cadwell LED stimulating goggles in 89 patients. Restrictive filtering (typically 10–100 Hz), optimal reject window settings, mastoid reference site, total intravenous anesthetic (TIVA), and stable retinal stimulation (ensured by concomitant electroretinogram [ERG] recording) were used to enhance FVEP reproducibility. Results: The relationship between FVEP amplitude change and visual outcome was determined from 179 eyes. One eye had a permanent intraoperative FVEP loss despite stable ERG, and this eye had new, severe postoperative visual dysfunction. Seven eyes had transient significant FVEP change (>50% amplitude decrease that recovered by the end of surgery), but only one of those had a decrease in postoperative visual acuity. FVEP changes in all eight eyes (one permanent FVEP loss plus seven transient FVEP changes) were related to surgical manipulation. In each case the surgeon was promptly informed of the FVEP deterioration and took remedial action. The other eyes did not have FVEP changes, and none of those eyes had new postoperative visual deficits. Conclusions: Our FVEP findings relate to visual outcome with a sensitivity and specificity of 1.0. New methods for rapidly acquiring reproducible FVEP waveforms allowed for timely reporting of significant FVEP change resulting in prompt surgical action. This may have accounted for the low postoperative visual deficit rate (1%) in this series.
Vitamin B12 is synthesised in the rumen from cobalt (Co) and has a major role in metabolism in the peri-paturient period, although few studies have evaluated the effect of the dietary inclusion of Co, vitamin B12 or injecting vitamin B12 on the metabolism, health and performance of high yielding dairy cows. A total of 56 Holstein-Friesian dairy cows received one of four treatments from 8 weeks before calving to 8 weeks post-calving: C, no added Co; DC, additional 0.2 mg Co/kg dry matter (DM); DB, additional 0.68 mg vitamin B12/kg DM; IB, intra-muscular injection of vitamin B12 to supply 0.71 mg/cow per day prepartum and 1.42 mg/cow per day post-partum. The basal and lactation rations both contained 0.21 mg Co/kg DM. Cows were weighed and condition scored at drying off, 4 weeks before calving, within 24 h of calving and at 2, 4 and 8 weeks post-calving, with blood samples collected at drying off, 2 weeks pre-calving, calving and 2, 4 and 8 weeks post-calving. Liver biopsy samples were collected from all animals at drying off and 4 weeks post-calving. Live weight changed with time, but there was no effect of treatment (P>0.05), whereas cows receiving IB had the lowest mean body condition score and DB the highest (P<0.05). There was no effect of treatment on post-partum DM intake, milk yield or milk fat concentration (P>0.05) with mean values of 21.6 kg/day, 39.6 kg/day and 40.4 g/kg, respectively. Cows receiving IB had a higher plasma vitamin B12 concentration than those receiving any of the other treatments (P<0.001), but there was no effect (P>0.05) of treatment on homocysteine or succinate concentrations, although mean plasma methylmalonic acid concentrations were lower (P=0.019) for cows receiving IB than for Control cows. Plasma β-hydroxybutyrate concentrations increased sharply at calving followed by a decline, but there was no effect of treatment. Similarly, there was no effect (P>0.05) of treatment on plasma non-esterified fatty acids or glucose. Whole tract digestibility of DM and fibre measured at week 7 of lactation were similar between treatments, and there was little effect of treatment on the milk fatty acid profile except for C15:0, which was lower in cows receiving DC than IB (P<0.05). It is concluded that a basal dietary concentration of 0.21 mg Co/kg DM is sufficient to meet the requirements of high yielding dairy cows during the transition period, and there is little benefit from additional Co or vitamin B12.
Indigenous women and children experience some of the most profound health disparities globally. These disparities are grounded in historical and contemporary trauma secondary to colonial atrocities perpetuated by settler society. The health disparities that exist for chronic diseases may have their origins in early-life exposures that Indigenous women and children face. Mechanistically, there is evidence that these adverse exposures epigenetically modify genes associated with cardiometabolic disease risk. Interventions designed to support a resilient pregnancy and first 1000 days of life should abrogate disparities in early-life socioeconomic status. Breastfeeding, prenatal care and early child education are key targets for governments and health care providers to start addressing current health disparities in cardiometabolic diseases among Indigenous youth. Programmes grounded in cultural safety and co-developed with communities have successfully reduced health disparities. More works of this kind are needed to reduce inequities in cardiometabolic diseases among Indigenous women and children worldwide.
Recent research has demonstrated the challenges to self-identity associated with dementia, and the importance of maintaining involvement in decision-making while adjusting to changes in role and lifestyle. This study aimed to understand the lived experiences of couples living with dementia, with respect to healthcare, lifestyle, and “everyday” decision-making.
Semi-structured qualitative interviews using Interpretative Phenomenological Analysis as the methodological approach.
Community and residential care settings in Australia.
Twenty eight participants who self-identified as being in a close and continuing relationship (N = 13 people with dementia, N = 15 spouse partners). Nine couples were interviewed together.
Participants described a spectrum of decision-making approaches (independent, joint, supported, and substituted), with these approaches often intertwining in everyday life. Couples’ approaches to decision-making were influenced by “decisional,” “individual,” “relational,” and “external” factors. The overarching themes of “knowing and being known,” “maintaining and re-defining couplehood” and “relational decision-making,” are used to interpret these experiences. The spousal relationship provided an important context for decision-making, with couples expressing a history and ongoing preference for joint decision-making, as an integral part of their experience of couplehood. However, the progressive impairments associated with dementia presented challenges to maintaining joint decision-making and mutuality in the relationship.
This study illustrates relational perspectives on decision-making in couples with dementia. Post-diagnostic support, education resources, proactive dyadic interventions, and assistance for spouse care partners may facilitate more productive attempts at joint decision-making by couples living with dementia.
Introduction: Pulmonary embolism (PE) is a diagnostic challenge, since it shares symptoms with other conditions. Missed diagnosis puts patients at a risk of a potentially fatal outcome, while false positive results leave them at risk of side effects (bleeding) from unnecessary treatment. Diagnosis involves a multi-step pathway consisting of clinical prediction rules (CPRs), laboratory testing, and diagnostic imaging, but the best strategy in the Canadian context is unclear. Methods: We carried out a systematic review of the diagnostic accuracy, clinical utility, and safety of diagnostic pathways, CPRs, and diagnostic imaging for the diagnosis of PE. Clinical prediction rules were studied by an overview of systematic reviews, and pathways and diagnostic imaging by a primary systematic review. Where feasible, a diagnostic test meta-analysis was conducted, with statistical adjustment for the use of variable and imperfect reference standards across studies. Results: The Wells CPR rule showed greater specificity than the Geneva, but the relative sensitivities were undetermined. Application of a CPR followed by with D-dimer laboratory testing can safely rule out PE. In diagnostic test accuracy meta-analysis, computed tomography (CT) (sensitivity 0.973, 95% CrI 0.921 to 1.00) and ventilation/perfusion single-photon emission CT (VQ-SPECT) (sensitivity 0.974, 95% CrI 0.898 to 1.00) had the highest sensitivity) and CT the highest specificity (0.987, 95% CrI 0.958 to 1.00). VQ and VQ-SPECT had a higher proportion of indeterminate studies, while VQ and VQ-SPECT involved lower radiation exposure than CT. Conclusion: CPR and D-dimer testing can be used to avoid unnecessary imaging. CT is the most accurate single modality, but radiation risk must be assessed. These findings, in conjunction with a recent health technology assessment, may help to inform clinical practice and guidelines.
Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &/or history of fever and 2 or more signs of hypoperfusion (eg. SBP<90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index >1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.
Established methods of recruiting population controls for case–control studies to investigate gastrointestinal disease outbreaks can be time consuming, resulting in delays in identifying the source or vehicle of infection. After an initial evaluation of using online market research panel members as controls in a case–control study to investigate a Salmonella outbreak in 2013, this method was applied in four further studies in the UK between 2014 and 2016. We used data from all five studies and interviews with members of each outbreak control team and market research panel provider to review operational issues, evaluate risk of bias in this approach and consider methods to reduce confounding and bias. The investigators of each outbreak reported likely time and cost savings from using market research controls. There were systematic differences between case and control groups in some studies but no evidence that conclusions on the likely source or vehicle of infection were incorrect. Potential selection biases introduced by using this sampling frame and the low response rate are unclear. Methods that might reduce confounding and some bias should be balanced with concerns for overmatching. Further evaluation of this approach using comparisons with traditional methods and population-based exposure survey data is recommended.
Unprotected n-3 PUFA supplements fed to ruminants are subject to lipolysis and biohydrogenation in the rumen (Wachira et al. 1998). Improving the n-3 PUFA content of ruminant products therefore requires some form of protection of dietary lipid from microbial activity in the rumen. The in-vitro incubation of PUFA sources offers the opportunity of rapidly determining the level of protection offered against ruminal biohydrogenation. The objectives of the current experiment were therefore to determine the biohydrogenation of a number of sources containing a-linolenic acid using the in-vitro gas production technique.
Increasing the n-3 polyunsaturated fatty acid (PUFA) content of ruminant products may be important in reducing the incidence of cardiovascular diseases in man. Previous experiments suggest that a-linolenic acid (C18:3n -3) in the form of whole linseed is extensively biohydrogenated both in vitro (Cooper et al., 2001) and in vivo (Wachira et al., 2000) and that some form of protection is required. By contrast the long chain PUFA’s in fish oils appear less susceptible to biohydrogenation (Wachira et al., 2000). The objective of the present study was to quantify the extent to which n-3 PUFA from different sources were biohydrogenated in the rumen and to determine the degree to which they were incorporated into plasma lipids.
Previous studies (e.g. Cia et al. 1998) have shown that modification of body composition of the prepubertal gilt has effects on responsiveness of gilts to exogenous gonadotrophin. Growing pigs are able to select a diet from different foods differing in protein:energy ratio (Dalby 1998); however there is little evidence of what effect the conflicting nutritional demands of growth and reproduction have on diet selection. The objectives of the experiment were to quantify the effects of choice feeding on responsiveness of gilts to exogenous gonadotrophin (Cia et al. 1998) and to investigate the effect of protein source on diet selection as Jones et al.(2000) have observed selection by breeding gilts against a high protein diet containing fishmeal.
The re-grouping of sows is a common procedure in pig production systems and is one which can have adverse consequences for both welfare and production (Arey and Edwards, 1998). Sows in an indoor dynamic group system, in which group structure was changed repeatedly, had a high rate of returns to service which may have been due to them receiving greater levels of aggression (Rigat et al., 1998). The aim of this experiment was to determine the effects of re-grouping on sow aggression and how this affected behaviour, immune function and productivity.
An adequate intake of colostrum by the newborn piglet allows the piglet to acquire passive immunity and develop active immunity. Many studies have looked at the uptake of IgG by piglets in artificial situations rather than by natural suckling. Therefore we investigated the uptake of IgG by piglets whilst suckling naturally and estimated the time of gut closure.
A total of 8 multiparous sows (Newsham - Large White x Landrace) were induced to farrow on day 114 of gestation. Colostrum/milk was sampled, using oxytocin where necessary, at 0, 4, 8, 12, 16, 20, 24h and 2, 5 and 7 days after farrowing. Female piglets (average 3 per litter) were fitted with umbilical catheters to allow blood sampling at 0, 4, 8, 12, 16, 20, 24 and 48h; samples were taken at 5 and 7 days of age by venepuncture.
Long-chain polyunsaturated fatty acids (PUFAs) are essential components of cellular membranes and are associated with prostaglandin synthesis. Supplementing ewes with long-chain PUFAs during gestation has been demonstrated to increase gestation length and improve lamb vigour (Capper et al., 2002). Furthermore, increasing the dietary vitamin E supplied to pregnant ewes is reported to increase lamb growth rate (Gentry et al., 1992). However, fish oil supplementation during lactation may reduce milk component yield and lamb growth rate (Capper et al., 2002). The objective of this experiment was to investigate the effects of dietary long-chain PUFA and vitamin E supplementation of pregnant ewes on lamb performance.
It is reported that supplementing pregnant ewes with supra-optimal levels of vitamin E improves neonatal lamb vigour and growth rate (Merrell, 1998). The biochemical mechanism behind these observations has yet to be elucidated as several studies report negligible placental vitamin E transfer in ruminants (Van Saun et al., 1989); consequently, lambs may be clinically deficient in this nutrient at birth and achieve a satisfactory vitamin E status via colostrum ingestion. Lamb vitamin E status may be further diminished by the addition of polyunsaturated fatty acids (PUFAs) to the maternal diet. However, PUFA supplementation demonstrably enhances foetal and neonatal development in human studies (Morley, 1998) although these effects have not been investigated in ruminants to any depth. The objective of this experiment was to investigate the effects of dietary vitamin E in combination with long-chain PUFA supplementation of ewes on ewe and lamb performance.
Starch and fat are the two major energy sources available for sow lactation diets. Fat is more energy dense and can be used to maximise energy intakes, particularly in sows with low appetite. However, the quantity of milk produced in sows has been associated with milk lactose production and the main precursor for lactose is glucose, for which dietary starch is the major source. It is therefore important to know the consequences of using a glucose deficient energy source, such as fat, compared to starch in lactation diets. The following experiment was designed to assess energy sources in lactation diets at an isocaloric level in determining sow and piglet performance, in association with the effects of dietary glucose availability on the metabolic state of the sow around peak lactation.
The long-chain polyunsaturated fatty acids (PUFA) docosahexaenoic acid (DHA) and arachidonic acid (AA) are the most abundant fatty acids in the brain and are vital for its correct development and for that of the nervous system (Huang and Craig-Schmidt, 1996). Ruminant diets are low in DHA and its precursor alpha-linolenic acid. In addition, dietary PUFAs are substantially hydrogenated in the rumen. Consequently, it may be argued that the diets of pregnant and lactating ewes may be deficient in DHA and that a response to supplementation may be observed. Studies involving the supplementation of pregnant ewes with supraoptimal levels of vitamin E have shown that lambs born to supplemented dams are more vigorous immediately after birth and have higher liveweight gains (Merrell, 1998). The objective of this experiment was to investigate the effects of dietary long-chain PUFA in combination with vitamin E supplementation of ewes on ewe and lamb performance.