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Aggression and violent incidents are a major concern in psychiatric in-patient care. Nutritional supplementation has been found to reduce aggressive incidents and rule violations in forensic populations and children with behavioural problems.
Aims
To assess whether multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation would reduce the number of aggressive incidents among long-stay psychiatric in-patients.
Method
The trial was a pragmatic, multicentre, randomised, double-blind placebo-controlled study. Data were collected from 25 July 2016 to 29 October 2019, at eight local sites for mental healthcare in The Netherlands and Belgium. Participants were randomised (1:1) to receive 6-month treatment with either three supplements containing multivitamins, minerals and n-3 polyunsaturated fatty acid, or placebo. The primary outcome was the number of aggressive incidents, determined by the Staff Observation Aggression Scale – Revised (SOAS-R). Secondary outcomes were patient quality of life, affective symptoms and adverse events.
Results
In total, 176 participants were randomised (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (s.d. 14.5) and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in supplement (1.03 incidents per month, 95% CI 0.74–1.37) and placebo groups (0.90 incidents per month, 95% CI 0.65–1.19), with a rate ratio of 1.08 (95% CI 0.67–1.74, P = 0.75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes.
Conclusions
Six months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric in-patients.
Until the past half-century, all agriculture and land management was framed by local institutions strong in social capital. But neoliberal forms of development came to undermine existing structures, thus reducing sustainability and equity. The past 20 years, though, have seen the deliberate establishment of more than 8 million new social groups across the world. This restructuring and growth of rural social capital within specific territories is leading to increased productivity of agricultural and land management systems, with particular benefits for those previously excluded. Further growth would occur with more national and regional policy support.
Surface melt on the coastal Antarctic ice sheet (AIS) determines the viability of its ice shelves and the stability of the grounded ice sheet, but very few in situ melt rate estimates exist to date. Here we present a benchmark dataset of in situ surface melt rates and energy balance from nine sites in the eastern Antarctic Peninsula (AP) and coastal Dronning Maud Land (DML), East Antarctica, seven of which are located on AIS ice shelves. Meteorological time series from eight automatic and one staffed weather station (Neumayer), ranging in length from 15 months to almost 24 years, serve as input for an energy-balance model to obtain consistent surface melt rates and energy-balance results. We find that surface melt rates exhibit large temporal, spatial and process variability. Intermittent summer melt in coastal DML is primarily driven by absorption of shortwave radiation, while non-summer melt events in the eastern AP occur during föhn events that force a large downward directed turbulent flux of sensible heat. We use the in situ surface melt rate dataset to evaluate melt rates from the regional atmospheric climate model RACMO2 and validate a melt product from the QuikSCAT satellite.
This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study.
Background:
Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences.
Methods:
Survey data were collected during 2011–2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling.
Findings:
Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care.
Conclusions:
The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor–patient relationship as well as a broad range of services offered by PC physicians.
This chapter lays out a conservation timeline, from past to future, for the Amsterdam version of Van Gogh's Sunflowers. It starts by considering the restoration history of the painting in order to assess its current physical state, and looks ahead to formulate an appropriate strategy for future conservation treatment and display. Due attention is paid to the two recorded episodes of restoration performed in 1927 and 1961 by the Dutch restorer, Jan Cornelis Traas. Based on physical and chemical investigation of Sunflowers we attempt to reconstruct what these former treatments (which are barely documented) entailed and consider the repercussions for the present condition of the painting. The former interventions by Traas also serve as a benchmark to reflect on current choices made, highlighting the extent to which ideas and methodologies have continued to evolve over the past century as conservation has moved further away from being a singularly craft-based activity to become an established historical and scientific discipline underpinned by ethical guidelines.
Jan Cornelis Traas (1898–1984)
As mentioned, the two main recorded interventions to the Amsterdam Sunflowers may be associated with the Dutch restorer, Jan Cornelis Traas, who treated the picture in 1927, close to the start of his career, and again in 1961, shortly before he retired. Traas was the first restorer to be appointed at the Mauritshuis in The Hague where he worked from 1931 to 1962 and treated hundreds of paintings, including iconic masterpieces such as Girl with a Pearl Earring by Johannes Vermeer. Yet despite the magnitude and importance of his restoration oeuvre, J.C. Traas (as he is usually referred to in surviving documents), has remained somewhat obscure. He is shown here in the only known surviving photograph of him at work, shortly before he retired (fig. 7.1). Unlike his illustrious contemporaries, A. Martin de Wild (1899–1969) and Helmut Ruhemann (1891–1973), for example, Traas did not publish anything, he appears to have kept no records of his work and no personal archive is known. However, the study of some newly discovered historical documents, combined with physical examination of Sunflowers and a large number of other works he treated, allows us to recover an idea of his working practices and approaches viewed within the context of his day.
Since its completion by Vincent van Gogh, the Amsterdam Sunflowers has been the subject of a complex history of interventions. Combined with the natural ageing and deterioration of the materials used by the artist, this has strongly affected the present appearance of the painting. The materials and techniques used in Sunflowers and related colour changes have been presented in chapters 4 and 5. This chapter focuses on characterizing the non-original surface layers present as well as secondary compounds arising from pigment-binder interaction in original paint components. The outcomes of this research help to reconstruct the restoration history of the painting and to understand its present condition, as a basis for optimizing future conservation treatment (as elaborated in chapter 7).
In keeping with Van Gogh's usual practice in the period, he left Sunflowers in an unvarnished state. Today, however, multiple layers of varnish are present. These have yellowed and make the painting appear highly glossy, whereas originally it presumably had the more subtle satin gloss related to pure oil paint. Conversely, some areas of the painting now look matt, since wax has been locally applied in the past.
Historical records provide sparse information regarding the surface layers added during earlier campaigns of treatment (see chapter 7). We know that the painting was varnished in 1927 by the conservator Jan Cornelis Traas, as part of a broader restoration and structural (lining) treatment. Remains of paper tape on the tacking margins of the painting are believed to date from this period (see chapter 7, p. 184). Further documents record that in 1961, Traas worked on the painting again. However, as there is no known account of what this treatment entailed, it remained in question whether Traas removed the 1927 varnish and/or applied new surface coating layers instead. Furthermore, in the late twentieth century, wax was applied in certain areas, used to matt down the glossy varnish and/or impregnate and consolidate the ground.
This chapter describes the outcome of the technical examinations of the Amsterdam Sunflowers, characterizing the surface layers present and assessing the history of application as revealed by their stratigraphy and chemical composition.
In this paper, we use formal asymptotic arguments to understand the stability properties of equivariant solutions to the Landau–Lifshitz–Gilbert model for ferromagnets. We also analyse both the harmonic map heatflow and Schrödinger map flow limit cases. All asymptotic results are verified by detailed numerical experiments, as well as a robust topological argument. The key result of this paper is that blowup solutions to these problems are co-dimension one and hence both unstable and non-generic.
To obtain a better understanding of how genetic and environmental processes are involved in the stability and change in problem behavior from early adolescence into adulthood, studies with genetically informative samples are important. The present study used parent-reported data on internalizing and externalizing problem behavior of adoptees at mean ages 12.4, 15.5 and 26.3. In this adoption study adopted biologically related sibling pairs shared on average 50% of their genes and were brought up in the same family environment, whereas adopted biologically unrelated sibling pairs only shared their family environment. The resemblance between these adopted biologically related (N = 106) and unrelated sibling pairs (N = 230) was compared and examined over time. We aimed to investigate (1) to what extent are internalizing and externalizing problem behavior stable from early adolescence into adulthood, and (2) whether the same or different genetic and environmental factors affect these problem behaviors at the 3 assessments. Our results show that both internalizing (rs ranging from .34 to .58) and externalizing behavior (rs ranging from .47 to .69) were rather stable over time. For internalizing and externalizing problem behavior it was found that both genetic and shared environmental influences could be modeled by an underlying common factor, which explained variance in problem behavior from early adolescence into adulthood and accounted for stability over time. The nonshared environmental influences were best modeled by a Cholesky decomposition for internalizing behavior, whereas a time-specific influence of the nonshared environment was included in the final model of externalizing behavior.
Biodiversity is the variability among living organisms, from genes to the biosphere. The value of biodiversity is multifold, from preserving the integrity of the biosphere as a whole, to providing food and medicines, to spiritual and aesthetic well-being.
One of the major drivers of biodiversity loss in Europe is atmospheric deposition of reactive nitrogen (Nr).
Approaches
This chapter focuses on Nr impacts on European plant species diversity; in particular, the number and abundance of different species in a given area, and the presence of characteristic species of sensitive ecosystems.
We summarise both the scientific and the policy aspects of Nr impacts on diversity and identify, using a range of evidence, the most vulnerable ecosystems and regions in Europe.
Key findings/state of knowledge
Reactive nitrogen impacts vegetation diversity through direct foliar damage, eutrophication, acidification, and susceptibility to secondary stress.
Species and communities most sensitive to chronically elevated Nr deposition are those that are adapted to low nutrient levels, or are poorly buffered against acidification. Grassland, heathland, peatland, forest, and arctic/montane ecosystems are recognised as vulnerable habitats in Europe; other habitats may be vulnerable but are still poorly studied.
It is not yet clear if different wet-deposited forms of Nr (e.g. nitrate, NO3− versus ammonium, NH4+) have different effects on biodiversity. However, gaseous ammonia (NH3) can be particularly harmful to vegetation, especially lower plants, through direct foliar damage.
To reduce the uncertainty in the calculation of Antarctic solid ice fluxes, the firn depth correction (Δh) in Antarctica is inferred from a steady-state firn densification model forced by a regional atmospheric climate model. The modelled density agrees well with observations from firn cores, apart from a site at the origin of fast flowing West Antarctic ice stream (Upstream B), where densification is anomalously rapid. The spatial distribution of Δh over Antarctica shows large variations, especially in the grounding line zone where large climate gradients exist. In places where the grounding line crosses ablation areas, Δh is zero. Along the remainder of the grounding line, Δh values range from typically 13 m in dry coastal areas (e.g. Dronning Maud Land) to 19 m in wet coastal areas (e.g. West Antarctica).
The work of the English Deist Thomas Morgan (d. 1743), a Marcion in his time, received much negative criticism in England and abroad, especially in Germany. His views aroused comments in books, dissertations and journals. Only in the first half of the twentieth century was he to be praised by theologians such as Adolf von Harnack and Emanuel Hirsch, who likewise disparaged the Old Testament.
Type 2 diabetes mellitus (DM2) is a common metabolic disorder. DM2 is
associated with cognitive impairments, and with depressive symptoms, which
occur in about one third of patients. In the current study we compared the
cognitive profile and psychological well-being of 119 patients with DM2
(mean age: 66 ± 6; mean duration: 9 ± 6 years) with 55 age
and education matched-control participants. Groups were compared on
cognitive performance in five major cognitive domains, psychological
wellbeing [assessed by Symptom Checklist (SCL)-90-R and the Beck
Depression Inventory (BDI-II)] and abnormalities on brain MRI. We
hypothesized an interrelationship between cognition, MRI abnormalities,
and psychological well-being. DM2 patients performed significantly worse
than controls on cognitive tasks, especially on tasks that required more
mental efficiency, although the differences were modest (effect sizes
Cohen d < .6). We speculate that DM2 patients have a
diminished ability to efficiently process unstructured information.
Patients with DM2 had significantly higher scores on the SCL-90-R
(p < .001) and on the BDI-II (p < .001) and worse
MRI ratings than controls, but psychological distress did not correlate
with cognition, MRI ratings or biomedical characteristics. Contrary to our
hypothesis, cognitive disturbances and psychological distress thus seem
independent symptoms of the same disease. (JINS, 2007,
13, 288–297.)
We investigate self-similar solutions of the thin film equation in the case of zero contact angle boundary conditions on a finite domain. We prove existence and uniqueness of such a solution and determine the asymptotic behaviour as the exponent in the equation approaches the critical value at which zero contact angle boundary conditions become untenable. Numerical and power-series solutions are also presented.
We study travelling wave solutions of a one-dimensional two-phase Free Boundary Problem, which models premixed flames propagating in a gaseous mixture with dust. The model combines diffusion of mass and temperature with reaction at the flame front, the reaction rate being temperature dependent. The radiative effects due to the presence of dust account for the divergence of the radiative flux entering the equation for temperature. This flux is modelled by the Eddington equation. In an appropriate limit the divergence of the flux takes the form of a nonlinear heat loss term. The resulting reduced model is able to capture a hysteresis effect that appears if the amount of fuel in front of the flame, or equivalently, the adiabatic temperature is taken as a control parameter.
We study the hole-filling problem for the porous medium equation $u_t= \frac{1}{m} \UDelta u^m$ with $m>1$ in two space dimensions. It is well known that it admits a radially symmetric self-similar focusing solution $u=t^{2\beta-1}F(|x|t^{-\beta})$, and we establish that the self-similarity exponent $\beta$ is a monotone function of the parameter $m$. We subsequently use this information to examine in detail the stability of the radial self-similar solution. We show that it is unstable for any $m>1$ against perturbations with 2-fold symmetry. In addition, we prove that as $m$ is varied there are bifurcations from the radial solution to self-similar solutions with $k$-fold symmetry for each $k=3,4,5,\dots.$ These bifurcations are simple and occur at values $m_3>m_4>m_5> \cdots\to1$.
The objective of this study was to assess patency of the internal jugular vein following modified radical or selective neck dissection and microvascular flap reconstruction by power Doppler ultrasound and its impact on free flap survival. In 23 patients who underwent selective or modified radical neck dissection and microvascular flap reconstruction the patency of the internal jugular vein was examined by power Doppler ultrasound on the first post-operative day and after follow-up of at least four months. On the first post-operative day in one patient partial thrombosis was found, while in the other 22 patients the internal jugular vein was normal patent. During follow-up in 17 (74 per cent) patients a normal patent internal jugular vein was found, while partial and complete thrombosis were found in three (13 per cent) patients each. On the first post-operative day 22 of the 23 (96 per cent) free flap veins were visualized. There was no free flap loss during follow-up. Power Doppler ultrasound is a valuable diagnostic technique for determination of internal jugular vein patency and may be useful as screening method or in case of clinical suspicion of thrombosis to determine internal jugular vein patency. Late internal jugular vein thrombosis may probably not effect free flap survival due to neovascularization.
To describe the results of the first year of the Dutch national surveillance of surgical-site infections (SSIs) and risk factors, which aims to implement a standardized surveillance system in a network of Dutch hospitals, to collect comparable data on SSIs to serve as a reference, and to provide a basic infrastructure for further intervention research.
Design:
Prospective multicenter cohort study.
Setting:
Acute-care hospitals in The Netherlands from June 1996 to May 1997.
Results:
38 hospitals participated, with a slight overrepresentation of larger hospitals. Following a total of 18,063 operations, 562 SSIs occurred, of which 198 were deep. Multivariate analysis of pooled procedures shows that age, preoperative length of stay, wound contamination class, anesthesia score, and duration of surgery were independent risk factors for SSI. When analyzed by procedure, the relative importance of these risk factors changed. Bacteriological documentation was available for 56% of the SSIs; 35% of all isolates were Staphylococcus aureus. Multiple regression analysis computed the mean extra postoperative length of stay associated with SSI to be 8.2 days.
Conclusion:
The first year of national surveillance has shown that it is feasible to collect comparable data on SSI, which are already used for education, policy, and decision making in the network of participating hospitals. This gives room to effectuate the next aim, namely to use the network as an infrastructure for intervention research. Multivariate analysis shows that feedback on a procedure-specific level is important.
To assess the relative importance of risk factors for surgical-site infections (SSIs) in orthopedic patients and thereby determine which risk factors to monitor in the national surveillance of SSI in The Netherlands.
Design:
Reanalysis of data on SSI and associated risk factors from two surveillance projects on nosocomial infections, carried out in 1992 and 1993 in The Netherlands: Project Surveillance Nosocomial Infections in the region of Utrecht (PSZU) and the first Project Surveillance Surgical Wound Infections (SWIFT-1). Odds ratios (ORs) were calculated for age, gender, preoperative stay, and the number of operations. In addition, in PSZU, other nosocomial infections, and, in SWIFT-1, prophylactic antibiotics, acute surgery, and wound contamination were studied.
Participants:
The study was confined to hospitalized orthopedic patients (PSZU, 4,872; SWIFT-1, 6,437).
Results:
In PSZU, the following ORs were significant in a multivariate model: age 0-44 years, 1.0; 45-64 years, 1.6; 65-74 years, 4.7; and 75-99 years, 6.0. For a preoperative stay over 4 days, the OR was 3.3 (95% confidence interval [CI95], 2.5-4.0), and for multiple surgery, 2.5 (CI95, 1.9-3.0). For females, the OR was 0.8 (not significant). The same model applied to SWIFT-1 gave similar ORs. Adjustment for additional nosocomial infections (PSZU) decreased the ORs for ages over 65 years remarkably. The OR for additional nosocomial infections in patients under 65 years of age was 15.6 (CI95, 4.3-57.4). Adjustment for prophylactic antibiotics, acute surgery, and wound-contamination class (SWIFT-1) did not influence the ORs of the original model, but showed that wound-contamination class was an important risk factor.
Conclusions:
Age, additional nosocomial infections, wound-contamination class, preoperative stay, and the number of operations were identified as important risk factors for SSI in Dutch orthopedic patients.
Traditionally, most arbitration acts provided that an arbitrator could be challenged on the same grounds as those on which judges could be challenged. Thus, arbitrators could be challenged on specific grounds, such as a family relationship with one of the parties or animosity towards one of the parties. The more modern approach is to provide for an open norm for the grounds on which challenges can be brought. This approach finds its origin in the UNCITRAL Arbitration Rules adopted in 1976. It provides that: “[a]n arbitrator may be challenged only if circumstances exist that give rise to the justifiable doubts as to his impartiality or independence”. This standard was received in many other arbitration acts and rules. The standard nowadays being more or less uniform, its interpretation and application are far from easy.