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Autism Spectrum Disorder (ASD) is a common neurodevelopmental disorder associated with difficulties in social communication and language development, preoccupations, a need for routine, sensory sensitivities and emotional dysregulation. People with autism who have violently offended may be prescribed psychotropic medications to treat comorbidities, or off-license to manage aggressive or challenging behaviours. However, the evidence base for their use remains scarce.
This was a retrospective audit at Broadmoor Hospital, a high security psychiatric hospital in the United Kingdom, into the safe and appropriate prescribing of psychotropic medicines in those with an ASD compared to guidance from the National Institute for Health and Care Excellence (CG142): “Autism spectrum disorder in adults: diagnosis and management”. This first cycle was undertaken during May and June 2020 and included all patients with a confirmed or equivocal diagnosis of ASD in the preceding five years.
A total of 22 participants were included in this study. Of these, 17 participants had a confirmed diagnosis of ASD and five participants had a suspected diagnosis of ASD, but without formal confirmation with neurocognitive testing. A total of 13 (76.5%) participants with confirmed ASD were prescribed antipsychotic medication, nine of whom had an established comorbid mental disorder with psychotic symptoms. Of the remaining four, three had a diagnosis of a personality disorder. Three participants in this study had a confirmed diagnosis of ASD without any additional comorbid mental health diagnoses. No patients were prescribed psychotropic medicines for the core symptoms of ASD. The specific documentation of off-license use of antipsychotic medicines in those without a diagnosis of a psychotic disorder was poor. This was not recorded in any such participant in the preceding 12 months.
This audit highlighted that dual diagnoses of ASD alongside non-affective psychosis and personality disorder are over-represented in this high security setting. The NICE clinical guidelines CG142 guidelines state that “antipsychotic medications should only be used for behaviour that challenges if …. the risk to the person or others is very severe”. By definition, all patients admitted to high security are deemed to be a grave and imminent risk to the public. Psychotropic medicines may therefore be clinically indicated at a much earlier stage than in community patients, instigated alongside appropriate psychosocial interventions and treatment of comorbid conditions. It may be that catered guidelines need to be formulated to support the safe and appropriate prescribing of psychotropic medicine in forensic settings.
Autism spectrum disorders (ASDs) are a group of lifelong neurodevelopmental disorders characterised by difficulties in social interactions and social communication, and restricted and repetitive behaviours. Relative to the general population, individuals with ASDs are likely to be overrepresented in secure psychiatric care and custodial settings. Outcomes vary and can be problematic in the context of co-occurring intellectual disability, psychiatric disorder and challenging behaviours. To date, there is little in the way of specialised clinical guidance on the prescription of psychotropic medicines for individuals with ASDs, particularly information on any differences in efficacy and/or tolerability of specific medications. This review summarises the key research to date on the prescription of psychotropic medication in ASD with and without comorbid psychiatric or neurodevelopmental disorders, within the context of the existing clinical guidance. Some critical analysis is provided to aid clinicians in following a safe, effective and individualised approach to prescribing for people with ASDs.
This report documents the last pteraspids, (armored, jawless members of the Heterostraci), which are otherwise only known from the Early Devonian of the Old Red Sandstone Continent. Tuberculate pteraspid heterostracans are described from the Middle Devonian beds of two formations in western North America. The late Givetian Yahatinda Formation of Alberta and British Columbia consists of channels cut into lower Paleozoic rocks and represents deposition in marine to littoral environments. Clavulaspis finis (Elliott et al., 2000a) new combination is redescribed from additional material from the Yahatinda Formation and reassigned to the new genus Clavulaspis because the original genus name is invalid. The Eifelian Spring Mountain beds of Idaho consist of a large channel that represents a clastic-dominated estuarine environment. It contains Scutellaspis wilsoni new genus new species, and the previously described species from the Spring Mountain beds is redescribed and reassigned to Ecphymaspis new genus, which was prompted by new material and a review of the validity of the original genus name. Phylogenetic analysis shows that these three new taxa form part of the derived clade Protaspididae.
In Wales, devolution signified an opportunity for the Welsh government to do politics differently. In particular, there was a focus on public participation as a mechanism for improvements to the economy, social outcomes and public services (Welsh Government, 2004). In ambition, at least, the devolution experiment in Wales anticipated the development of regulations for the engagement of its citizens. This chapter considers the role of community anchor organisations in the ‘flagship’ regeneration programme of the National Assembly for Wales, ‘Communities First’, launched in 2001 and later terminated in March 2018. The programme started as a ‘bottomup’ initiative for engaging with disadvantaged communities at the margins, setting up regulatory structures to deliver that vision; became a reduced and more competitive programme from 2008/09, with more defined outcomes; and then entered its final phase in 2012, with ‘clusters’ of communities that were expected to deliver governmentdriven outcomes on health, learning and, in particular, employability through a system of results-based accountability (RBA). In the process, regulation for engagement shifted to regulatory structures and processes that controlled engagement: the regulation of engagement.
Other research has traced the evolution of the programme (Pearce, 2012; Dicks, 2014) in the context of a bold policy experiment in a devolved context while the programme was still live. This chapter, however, unpicks the story of its evolution and demise from the perspectives of community development advisors and community development practitioners, the latter based in two community organisations in South Wales: South Riverside Community Development Centre (SRCDC) in Cardiff and 3Gs Community Development Trust in Merthyr Tydfil. Both organisations were involved in the Productive Margins programme and in the design and analysis of this research. Both pre-existed the Communities First programme and were charged with its delivery to local people. We look at the regulatory context in which these organisations found themselves and how they negotiated the demands of the state-funded programme, on the one hand, and their accountabilities to the communities that they believed they represented, on the other. A key question remains as to whether the involvement of community organisations in state-funded programmes can facilitate regulation for engagement for social change or whether their power to improve the well-being of the communities they represent might better be served in providing alternative modes of living.
Sensory trademarks present a compelling case in which to explore the senses as “containers of possibility,” and this article explores the emergence and logic of sensory trademarks from a legal and marketers’ perspective. Using sensory trademark cases from the United States, I suggest that the current socio-legal environment opens a conversation about what I would call sensory capitalism—the monetization of the senses rather than the propertization of the senses—that requires intellectual property law to properly function. I argue that the sensory model espoused by the trademarking of the senses is one of the mass sensorium, whereby the “audience” universally recognizes marks as designating a particular source or origin of goods. The mass sensorium offers something quite novel, however, because embedded in it is the (corporate) promise of a lingua franca that valorizes all of the senses and generates a type of mediated affect that is shared.
Objective: Post-stroke cognitive impairment is common, but mechanisms and risk factors are poorly understood. Frailty may be an important risk factor for cognitive impairment after stroke. We investigated the association between pre-stroke frailty and acute post-stoke cognition. Methods: We studied consecutively admitted acute stroke patients in a single urban teaching hospital during three recruitment waves between May 2016 and December 2017. Cognition was assessed using the Mini-Montreal Cognitive Assessment (min=0; max=12). A Frailty Index was used to generate frailty scores for each patient (min=0; max=100). Clinical and demographic information were collected, including pre-stroke cognition, delirium, and stroke-severity. We conducted univariate and multiple-linear regression analyses with covariates forced in (covariates included were: age, sex, stroke severity, stroke-type, pre-stroke cognitive impairment, delirium, previous stroke/transient ischemic attack) to investigate the association between pre-stroke frailty and post-stroke cognition. Results: Complete data were available for 154 stroke patients. Mean age was 68 years (SD=11; range=32–97); 93 (60%) were male. Median mini-Montreal Cognitive Assessment score was 8 (IQR=4–12). Mean Frailty Index score was 18 (SD=11). Pre-stroke cognitive impairment was apparent in 13/154 (8%) patients. Pre-stroke frailty was significantly associated with lower post-stroke cognition (Standardized-Beta=−0.40; p<0.001) and this association was independent of covariates (Unstandardized-Beta=−0.05; p=0.005). Additional significant variables in the multiple regression model were age (Unstandardized-Beta=−0.05; p=0.002), delirium (Unstandardized-Beta=−2.81; p<0.001), pre-stroke cognitive impairment (Unstandardized-Beta=−2.28; p=0.001), and stroke-severity (Unstandardized-Beta=−0.20; p<0.001). Conclusions: Pre-stroke frailty may be a moderator of post-stroke cognition, independent of other well-established post-stroke cognitive impairment risk factors. (JINS, 2019, 25, 501–506)
Two chondrichthyan assemblages of Late Mississippian/Early Pennsylvanian age are now recognized from the western Grand Canyon of northern Arizona. The latest Serpukhovian Surprise Canyon Formation has yielded thirty-one taxa from teeth and dermal elements, which include members of the Phoebodontiformes, Symmoriiformes, Bransonelliformes, Ctenacanthiformes, Protacrodontoidea, Hybodontiformes, Neoselachii (Anachronistidae), Paraselachii (Gregoriidae, Deeberiidae, Orodontiformes, and Eugeneodontiformes), Petalodontiformes, and Holocephali. The euselachian grade taxa are remarkably diverse with four new taxa recognized here; the Protacrodontidae: Microklomax carrieae new genus new species and Novaculodus billingsleyi new genus new species, and the Anchronistidae: Cooleyella platera new species and Amaradontus santucii new genus new species The Surprise Canyon assemblage also has the youngest occurrence of the elasmobranch Clairina, previously only known from the Upper Devonian. The Surprise Canyon Formation represents a nearshore fluvial infilling of karstic channels, followed by a shallow marine bioherm reef, and finally deeper open water deposition. The early Bashkirian Watahomigi Formation represents open marine deposition and contains only two taxa: a new xenacanthiform, Hokomata parva new genus new species, and the holocephalan Deltodus. The relationship between the Surprise Canyon and Watahomigi chondrichthyan assemblages and other significant coeval chondrichthyan assemblages suggests that there may have been eastern and western distinctions among the Euamerican assemblages during the Serpukhovian due to geographic separation by the formation of Pangea.
Background: Neurosurgical residents face a unique combination of challenges, including long duty hours, technically challenging cases, and uncertain employment prospects. We sought to assess the demographics, interests, career goals, self-rated happiness, and overall well-being of Canadian neurosurgery residents. Methods: A cross-sectional survey was developed and sent through the Canadian Neurosurgery Research Collaborative to every resident enrolled in a Canadian neurosurgery program as of April 1, 2016. Results: We analyzed 76 completed surveys of 146 eligible residents (52% response rate). The median age was 29 years, with 76% of respondents being males. The most popular subspecialties of interest for fellowship were spine, oncology, and open vascular neurosurgery. The most frequent self-reported number of worked hours per week was the 80- to 89-hour range. The majority of respondents reported a high level of happiness as well as stress. Sense of accomplishment and fatigue were reported as average to high and overall quality of life was low for 19%, average for 49%, and high for 32%. Satisfaction with work-life balance was average for 44% of respondents and was the only tested domain in which significant dissatisfaction was identified (18%). Overall, respondents were highly satisfied with their choice of specialty, choice of program, surgical exposure, and work environment; however, intimidation was reported in 36% of respondents and depression by 17%. Conclusions: Despite a challenging residency and high workload, the majority of Canadian neurosurgery residents are happy and satisfied with their choice of specialty and program. However, work-life balance, employability, resident intimidation, and depression were identified as areas of active concern.
Three new species of the new genus Phyllonaspis are described from Early Devonian localities in the western United States. Phyllonaspis laevis, P. serratus, and P. taphensis are broad, flattened cyathaspids with lateral brims and fine dermal ornament, that show a close relationship to the cyathaspids Boothiaspis and Alainaspis from the late Silurian and Early Devonian of the Canadian Arctic. These taxa are here accommodated within the new subfamily Boothiaspidinae within the family Cyathaspididae. This relationship supports previous evidence of faunal connection between these two areas and indicates dispersal around the Old Red Sandstone Continent from a center in the Canadian Arctic. Isolated oral plates allow a reconstruction of the oral cover and increase our knowledge of the range of oral structures in this family.
Ernietta plateauensis Pflug, 1966 is the type species of the Erniettomorpha, an extinct clade of Ediacaran life. It was likely a gregarious, partially infaunal organism. Despite its ecological and taxonomic significance, there has not been an in-depth systematic description in the literature since the original description fell out of use. A newly discovered field site on Farm Aar in southern Namibia has yielded dozens of specimens buried in original life position. Mudstone and sandstone features associated with the fossils indicate that organisms were buried while still exposed to the water column rather than deposited in a flow event. Ernietta plateauensis was a sac-shaped erniettomorph with a body wall constructed from a double layer of tubes. It possessed an equatorial seam lying perpendicular to the tubes. The body is asymmetrical on either side of this seam. The tubes change direction along the body length and appear to be constricted together in the dorsal part of the organism.
This collection of essays explores themes and controversies (legal, political and scholarly) in public law which are subjects of current debate in that area, while also (we hope) contributing to those debates from both practical and theoretical perspectives. The purposes of this Introduction are to set the scene by outlining the political context in which public law and its scholarship have developed over the past forty or so years, and to locate within that context and in relation to each other some of the themes which our contributors develop in the chapters which follow.
The context in which public law develops and operates
At the risk of pre-empting what follows, one can say that public law is concerned with the state – its structures, the actions and interactions of its institutions and people who operate them, the principles and mechanisms on which it runs – and its relationships with other entities and individuals inside and outside the state. These structures and relationships are not static. They change constantly in response to developments in ideas about the role of states in society and to changing political dynamics. Whilst many states are thought to be stable, they are at best maintaining an unstable equilibrium between competing forces, and can easily be tipped out of that equilibrium by unexpected changes. These may be economic or financial, as we saw in 2008 when shocks to the banking system of much of the western world reduced many states to dependency on other states and international organisations. As a result, Greece, Cyprus, Italy, Spain and Portugal, among other states, suffered a severe loss of control over their political as well as economic futures. This may prove to have been only a temporary phenomenon, but it is hard to believe that it will not have a long-term effect on states’ assessments of their own relative independence and authority. Other challenges to states come in the form of political or economic ideologies. Over the last thirty-five years, there have been huge changes in ideas about the state in many countries.
The Cambridge Companion to Public Law examines key themes, debates and issues in contemporary public law. The book identifies and draws out five key themes: the notions of government and the state; the place of the state and public law in the world at large; relationships between institutions and officials within the state; the legitimacy of institutions; and the identity and value of public law in relation to politics. The book also presents a contemporary examination, taking account of the substantial changes witnessed in this area in recent decades and of the resulting need to reassess orthodox accounts of the subject. Written by leading authorities drawn from across the common law world, their approach is rigorous, engaging and highly accessible. This Companion acts as both a thoughtful introduction and a collection that consciously moves the discipline forward.
The objective of this study was to compare the emergency department (ED) management and rate of admission of acute decompensated heart failure (ADHF) between two hospitals in Canada and the United States and to compare the outcomes of these patients.
This was a health records review of adults presenting with ADHF to two EDs in Canada and the United States between January 1 and April 30, 2010. Outcome measures were admission to the hospital, myocardial infarction (MI), and death or relapse rates to the ED. Data were analysed using descriptive, univariate and multivariate analyses.
In total, 394 cases were reviewed and 73 were excluded. Comparing 156 Canadian to 165 U.S. patients, respectively, mean age was 76.0 and 75.8 years; male sex was 54.5% and 52.1%. Canadian and U.S. ED treatments were noninvasive ventilation 7.7% v. 12.8% (p=0.13); IV diuretics 77.6% v. 36.0% (p<0.001); IV nitrates 4.5% v. 6.7% (p=0.39). There were significant differences in rate of admission (50.6% v. 95.2%, p<0.001) and length of stay in ED (6.7 v. 3.0 hours, p<0.001). Proportion of Canadian and U.S. patients who died within 30 days of the ED visit was 5.1% v. 9.7% (p=0.12); relapsed to the ED within 30 days was 20.8% v. 17.5% (p=0.5); and had MI within 30 days was 2.0% v. 1.9% (p=1.0).
The U.S. and Canadian centres saw ADHF patients with similar characteristics. Although the U.S. site had almost double the admission rate, the outcomes were similar between the sites, which question the necessity of routine admission for patients with ADHF.