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Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings.
A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals.
Factors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers’ involvement in the implementation differed between the units.
Significance of the results
The feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.
Most algorithms to extract dry snowpack water equivalent (SWE) from satellite passive-microwave observations are based on point measurements of SWE or extrapolation of point measurements to the 30 km footprint of the satellite observations. SWE observations on a scale comparable to the satellite observations can be obtained from airborne gamma-ray attenuation techniques from flight lines that are approximately 10 km long. During the winter of 1989, the NOAA National Operational Hydrologic Remote Sensing Center (NOHRSC) flew 92 of these night lines over a 200 × 250 km area of the Red River basin which is located in the north-central part of the United States of America. These observations provide a unique dataset of snow water-equivalent determinations on spatial scales similar to the satellite passive-microwave observations as acquired by the Defense Meteorological Satellite Program (DMSP) Special Sensor Microwave Imager (SSM/I) F-8 satellite. Land-classification determinations from the Advanced Very High Resolution Radiometer (AVHRR) show that the eastern part of the region contains a coniferous forest of varying coverage, while the remainder is farmland or prairie. SSM/I data, including observations from a no-snow case in the preceding fall, the flight-line data and the AVHRR data were all co-registered to a common 20 km grid. The resulting dataset was analyzed using linear regression, artificial intelligence and general linear models. The results showed that the passive-microwave response was similar to the response predicted by Mie scattering theory. A comparison of the three techniques found that the artificial intelligence technique and the general linear model explained significantly more of the variance in the dataset, as evidenced by R2 values of 0.97 compared to 0.88 for the linear multiple-regression analysis. Hence, a neural network approach which was continually trained on new datasets as they became available, could provide better estimates of snowpack water equivalent than algorithms based on linear-regression techniques.
We present a new 3D MHD code for the simulation of solar magnetoconvection. The code is designed for use on parallel computers and in the choice of methods emphasis has been laid on efficient parallelization. We give a description of the numerical methods and discuss the non-local and non-grey treatment of the radiative transfer. Test calculations underlining the importance of non-grey effects and first results of the simulation of a solar plage region are shown.
Blazar OJ 287 is one of the best observed extragalactic objects. It's historical light curve goes back to 1890′s. Based on the historical behaviour Sillanpää et al. (1988) showed that OJ 287 displays large periodic outbursts, with a period of 11.7 years. We have monitored OJ 287 intensively for two years, during the OJ-94 project. This project was created for monitoring OJ 287 during its predicted new outburst in 1994. In the data archive we have over 7000 observations on OJ 287, in the radio, infrared and optical bands. This data archive contains the best ever obtained light curves for any extragalactic object. The optical light curve shows continuous variability down to time scales of tens of minutes. The variability observed in OJ 287 can be broken down to (at least) four different categories:
Nutrient-rich food (NRF) index scores are dietary quality indices based on nutrient density. We studied the design aspects involved in the development and validation of NRF index scores, using the Dutch consumption data and guidelines as an example. We evaluated fifteen NRF index scores against the Dutch Healthy Diet Index (DHD-index), a measure of adherence to the Dutch dietary guidelines, and against energy density. The study population included 2106 adults from the Dutch National Food Consumption Survey 2007–2010. The index scores were composed of beneficial nutrients (protein, fibre, fatty acids, vitamins, minerals), nutrients to limit (saturated fat, sugar, Na) or a combination. Moreover, the influence of methodological decisions was studied, such as the choice of calculation basis (100 g or 100 kcal (418 kJ)). No large differences existed in the prediction of the DHD-index by the fifteen NRF index scores. The score that best predicted the DHD-index included nine beneficial nutrients and three nutrients to limit on a 100-kcal basis, the NRF9.3 with a model R2 of 0·34. The scores were quite robust with respect to sex, BMI and differences in calculation methods. The NRF index scores were correlated with energy density, but nutrient density better predicted the DHD-index than energy density. Consumption of vegetables, cereals and cereal products, and dairy products contributed most to the individual NRF9.3 scores. In conclusion, many methodological considerations underlie the development and evaluation of nutrient density models. These decisions may depend upon the purpose of the model, but should always be based upon scientific, objective and transparent criteria.
Uteroplacental insufficiency resulting in intrauterine growth restriction has been associated with the development of cardiovascular disease, coronary heart disease and increased blood pressure, particularly in males. The molecular mechanisms that result in the programming of these phenotypes are not clear. This study investigated the expression of cardiac JAK/STAT signalling genes in growth restricted offspring born small due to uteroplacental insufficiency. Bilateral uterine vessel ligation was performed on day 18 of pregnancy to induce growth restriction (Restricted) or sham surgery (Control). Cardiac tissue at embryonic day (E) 20, postnatal day (PN) 1, PN7 and PN35 in male and female Wistar (WKY) rats (n=7–10 per group per age) was isolated and mRNA extracted. In the heart, there was an effect of age for males for all genes examined there was a decrease in expression after PN1. With females, JAK2 expression was significantly reduced after E20, while PI3K in females was increased at E30 and PN35. Further, mRNA expression was significantly altered in JAK/STAT signalling targets in Restricteds in a sex-specific manner. Compared with Controls, in males, JAK2 and STAT3 were significantly reduced in the Restricted, while in females SOCS3 was significantly increased and PI3K significantly decreased in the Restricted offspring. Finally, there were specific differences in the levels of gene expression within the JAK/STAT pathway when comparing males to females. Thus, growth restriction alters specific targets in the JAK/STAT signalling pathway, with altered JAK2 and STAT3 potentially contributing to the increased risk of cardiovascular disease in the growth restricted males.
The most accurate method to estimate Na and K intakes is to determine 24 h urinary excretions of these minerals. However, collecting 24 h urine is burdensome. Therefore it was studied whether spot urine could be used to replace 24 h urine samples.
Participants collected 24 h urine and kept one voiding sample separate. Na, K and creatinine concentrations were analysed in both 24 h and spot urine samples. Also 24 h excretions of Na and K were predicted from spot urine concentrations using the Tanaka and Danish methods.
In 2011 and 2012, urine samples were collected and brought to the study centre at Wageningen University, the Netherlands.
Women (n 147) aged 19–26 years.
According to p-aminobenzoic acid excretions, 127 urine collections were complete. Correlations of Na:creatinine, K:creatinine and Na:K between spot urine and 24 h urine were 0·68, 0·57 and 0·64, respectively. Mean 24 h Na excretion predicted with the Tanaka method was higher (difference 21·2 mmol/d, P<0·001) than the measured excretion of 131·6 mmol/d and mean 24 h Na excretion predicted with the Danish method was similar (difference 3·2 mmol/d, P=0·417) to the measured excretion. The mean 24 h K excretion predicted with the Tanaka method was higher (difference 13·6 mmol/d, P<0·001) than the measured excretion of 66·8 mmol/d. Bland–Altman plots showed large individual differences between predicted and measured 24 h Na and K excretions.
The ratios of Na:creatinine and K:creatinine in spot urine were reasonably well associated with their respective ratios in 24 h urine and appear to predict mean 24 h Na excretion of these young, Caucasian women.
The Dutch Healthy Diet index (DHD-index) was developed using data from two 24 h recalls (24hR) and appeared useful to evaluate diet quality in Dutch adults. As many epidemiologic studies use FFQ, we now estimated the DHD-index score using FFQ data. We compared whether this score showed similar associations with participants' characteristics, micronutrient intakes, and biomarkers of intake and metabolism compared with the DHD-index using 24hR data. Data of 121 Dutch participants of the European Food Consumption Validation study were used. Dietary intake was assessed by two 24hR and a 180-item FFQ. Biomarkers measured were serum total cholesterol and carotenoids, EPA + DHA in plasma phospholipids and 24 h urinary Na. A correlation of 0·48 (95 % CI 0·33, 0·61) was observed between the DHD-index score based on 24hR data and on FFQ data. Classification of participants into the same tertiles of the DHD-index was achieved for 57 %. Women showed higher DHD-index scores. Energy intake was inversely associated with both DHD-index scores. Furthermore, age and intakes of folate, Fe, Mg, K, vitamin B6 and vitamin C were positively associated with both DHD-index scores. DHD-index scores showed acceptable correlations with the four combined biomarkers taking energy intake into account (r24hR 0.55; rFFQ 0.51). In conclusion, the DHD-index score based on FFQ data shows similar associations with participants' characteristics, energy intake, micronutrient intake and biomarkers compared with the score based on 24hR data. Furthermore, ranking of participants was acceptable for both methods. FFQ data may therefore be used to assess diet quality using the DHD-index in Dutch populations.
The role of interfacial exchange coupling in the magnetic behavior of metal oxide materials has been investigated through the study of Fe3O4/NiO superlattices. We report results on a series of superlattices grown where one bilayer constituent was held to a fixed thickness while varying the other from single unit cell dimensions upward. High crystalline quality was confirmed by XRD, RHEED and neutron diffraction. Magnetization profiles show substantial deviations from bulklike iron oxide results, with an increase in domain rotation energies observed in the superlattices over that of bulk iron oxide (increasing with NiO layer thickness) indicating the strong nature of Fe3O4/NiO interfacial linkage. Neutron scattering at elevated temperatures shows that the NiO remains ordered above the 523 K bulk Néel temperature. This suggests that at least a portion of the NiO within a layer remains ordered well above the Néel temperature, with an increase in effective Néel transition temperature that approaches the Fe3O4 Curie temperature in the limit of very thin NiO layers. Although the exchange coupling dominates these effects, strain also plays an important role.
The velocity distributions of atoms evaporated from the surface of GaAs during laser heating with nanosecond and picosecond pulses are measured. The atomic velocities provide information about the surface temperature. For picosecond heating we observe a continuous transition of the temperature across the melting point, whereas for nanosecond heating the melting point is marked by a distinct plateau of the temperature curve. From these observations we conclude that the solid is strongly superheated during picosecond irradiation. A detailed analysis suggests superheating of typically a few hundred degrees above the melting point.
We have investigated the magnetic order, using SQUID magnetometry, for short modulation wavelength Fe3O4/NiO superlattices, grown on single crystal MgO. Ferrimagnetic Fe3O4 has a saturation moment of ~500 emu/cm3 at 0 K and a Curie temperature of 858 K, while bulk NiO is antiferromagnetic with a NMel temperature of 525 K. Very high crystalline quality with little interdiffusion is indicated by X-ray diffraction, SEM, optical microscopy, and in-situ RHEED, and the samples show highly anisotropic electrical conductivity which also indicates the strong modulation present. Long wavelength samples (Amod > 200 Å) have a behavior only slightly different from that expected from bulk Fe3O4, but for Amod<80 Å, spontaneous magnetization is replaced by paramagnetism, with weak temperature dependence (not I/T) from 5 K to 400 K.
The term Rapid Manufacturing is today very often used as a substitute for Rapid Prototyping, because the manufacturing processes and materials have developed so much that the parts produced with the machines can even be used as functional production parts. For Direct Metal Laser Sintering (DMLS) this was enabled by the introduction of the powders for 20 micron layer thickness; steel-based powder in 2001 and bronze-based powder in 2002. Successful rapid manufacturing with DMLS does not only mean the reduction of layer thickness, but it is a sum of many factors that had to be optimized in order to make the process work with the 20 micron layer thickness: the metal powder behavior in very thin layers is not the same as with thicker layers, the demands for the support structures are higher and the possibility of using multiples of the layer thickness gives additional freedom. By optimizing the process parameters the UTS values for the steel-based powder increased up to 600 MPa and for the bronze-based powder up to 400 MPa. At the same time the surface roughness (Ra) values after shot peening were 3 microns and 2 microns, respectively. Although using thinner layers also increases the building time the advantage is gained in drastically reduced finishing times due to increased surface quality and detail resolution. Typical geometries produced by DMLS are difficult-to-manufacture components and components typically produced by P/M or even by die-casting. The paper covers the development aspects in both material and process development and also presents some realized case studies.
Image sensors in TFA (Thin Film on ASIC) technology have been successfully fabricated and tested. This paper provides a survey of TFA research results so far and outlines future perspectives. The properties of different a-Si:H b/w and color thin film detectors are evaluated, including spectral sensitivity, dark current, temperature influence and transient behavior. Furthermore several TFA prototypes and emerging concepts are presented, ranging from a simple one-transistor cell design to a locally autoadaptive sensor.
Ultrafast time-resolved X-ray diffraction has been used to study the dynamics of coherent acoustic phonons in fs laser-excited Ge and Au, with the particular goal to clarify the interplay of the electronic and thermal pressure contributions. For semiconductors it is usually assumed that the electronic pressure is the dominant driving force. Our measurements reveal that in Ge the relative strength of the electronic pressure decreases with increasing laser fluence. Only for low fluences the electronic pressure dominates, while at high fluences the thermal pressure exceeds the electronic pressure. For the case of Au the data are well described within the established theoretical framework using the known values for those material parameters which determine the laser-induced pressure, namely the energy relaxation time and the electronic and lattice Grüneisen parameters.
We show that time-resolved electron diffraction is capable of revealing the ultrafast lattice heating in thin metal films following excitation by a femtosecond laser pulse. The build-up of the lattice temperature leads to a reduction of the diffraction intensity of the various diffraction orders due to the Debye-Waller-effect. We also observed a reduction of the transmitted (000)-signal which exhibits the same temporal evolution as the diffraction signals.
Large amplitude coherent optical phonons have been investigated in laser-excited Bismuth by means of femtosecond time-resolved X-ray diffraction. For absorbed laser fluences above 2 mJ/cm2, the experimental data reveal an extreme softening of the excited A1g-mode down to frequencies of about 1 THz, only 1/3 of the unperturbed A1g-frequency. At even stronger excitation the measured diffraction signals no longer exhibit an oscillatory behavior presenting strong indication that upon intense laser-excitation the Peierls-distortion, which defines the equilibrium structure of Bismuth, can be transiently reversed.
A multistate outbreak of Escherichia coli O157:H7 infections occurred in the USA in November–December 2006 in patrons of restaurant chain A. We identified 77 cases with chain A exposure in four states – Delaware, New Jersey, New York, and Pennsylvania. Fifty-one (66%) patients were hospitalized, and seven (9%) developed haemolytic uraemic syndrome; none died. In a matched analysis controlling for age in 31 cases and 55 controls, illness was associated with consumption of shredded iceberg lettuce [matched odds ratio (mOR) 8·0, 95% confidence interval (CI) 1·1–348·1] and shredded cheddar cheese (mOR 6·2, CI 1·7–33·7). Lettuce, an uncooked ingredient, was more commonly consumed (97% of patients) than cheddar cheese (84%) and a single source supplied all affected restaurants. A single source of cheese could not explain the regional distribution of outbreak cases. The outbreak highlights challenges in conducting rapid multistate investigations and the importance of incorporating epidemiological study results with other investigative findings.
Attitudes and expectations about treatment have been associated with symptomatic outcomes, adherence and utilization in patients with psychiatric disorders. No measure of patients' anticipated benefits of treatment on domains of everyday functioning has previously been available.
The Anticipated Benefits of Care (ABC) is a new, 10-item questionnaire used to measure patient expectations about the impact of treatment on domains of everyday functioning. The ABC was collected at baseline in adult out-patients with major depressive disorder (MDD) (n=528), bipolar disorder (n=395) and schizophrenia (n=447) in the Texas Medication Algorithm Project (TMAP). Psychometric properties of the ABC were assessed, and the association of ABC scores with treatment response at 3 months was evaluated.
Evaluation of the ABC's internal consistency yielded Cronbach's α of 0.90–0.92 for patients across disorders. Factor analysis showed that the ABC was unidimensional for all patients and for patients with each disorder. For patients with MDD, lower anticipated benefits of treatment was associated with less symptom improvement and lower odds of treatment response [odds ratio (OR) 0.72, 95% confidence interval (CI) 0.57–0.87, p=0.0011]. There was no association between ABC and symptom improvement or treatment response for patients with bipolar disorder or schizophrenia, possibly because these patients had modest benefits with treatment.
The ABC is the first self-report that measures patient expectations about the benefits of treatment on everyday functioning, filling an important gap in available assessments of attitudes and expectations about treatment. The ABC is simple, easy to use, and has acceptable psychometric properties for use in research or clinical settings.
Effective infection control measures during norovirus outbreaks are urgently needed in places where vulnerable individuals gather. In the present study, the effect of a number of measures was investigated in daily practice. Forty-nine Dutch nursing homes were monitored prospectively for norovirus outbreaks during two winter seasons. A total of 37 norovirus outbreaks were registered. Control measures were most effective when implemented within 3 days after onset of disease of the first patient. Measures targeted at reduced transmission between persons, via aerosols, and via contaminated surfaces reduced illness in staff and in residents. Reducing illness in staff results in fewer costs for sick leave and substitution of staff and less disruption in the care of residents. The effect of control measures on outbreak duration was limited. This is the first intervention study examining the effect of control measures. Further research is needed to extend and refine the conclusions.
Across their range jaguars Panthera onca are important conservation icons for several reasons: their important role in ecosystems as top carnivores, their cultural and economic value, and their potential conflicts with livestock. However, jaguars have historically been difficult to monitor. This paper outlines the first application of a systematic camera trapping methodology for abundance estimation of jaguars. The methodology was initially developed to estimate tiger abundance in India. We used a grid of camera traps deployed for 2 months, identified individual animals from their pelage patterns, and estimated population abundance using capture-recapture statistical models. We applied this methodology in a total of five study sites in the Mayan rainforest of Belize, the Chaco dry forest of Bolivia, and the Amazonian rainforest of Bolivia. Densities were 2.4–8.8 adult individuals per 100 km2, based on 7–11 observed animals, 16–37 combined ‘captures’ and ‘recaptures’, 486–2,280 trap nights, and sample areas of 107–458 km2. The sampling technique will be used to continue long-term monitoring of jaguar populations at the same sites, to compare with further sites, and to develop population models. This method is currently the only systematic population survey technique for jaguars, and has the potential to be applied to other species with individually recognizable markings.