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As the population continues to age, clinicians will increasingly encounter neurological conditions in routine clinical practice. Neurological problems in the elderly have a profound impact on quality of life and can at times be life-threatening. Diagnosis and management of geriatric neurological problems is complicated by often vague presentations and the presence of comorbid conditions, as well as complex physiology and pharmacology in this age group. Moreover, when caring for these patients it is of utmost importance to have a holistic approach and include family and caregivers when developing care plans. In this chapter we review muscle weakness, sensory loss, seizure disorders, and headaches in the elderly patient. Causes, impact on quality of life, and available treatment options are discussed. Other topics including delirium, dementia, cerebrovascular disease, and gait disorders will be covered elsewhere.
Glacier motion responds dynamically to changing meltwater inputs, but the multi-decadal response of basal sliding to climate remains poorly constrained due to its sensitivity across multiple timescales. Observational records of glacier motion provide critical benchmarks to decode processes influencing glacier dynamics, but multi-decadal records that precede satellite observation and modern warming are rare. Here we present a record of motion in the ablation zone of Saskatchewan Glacier that spans seven decades. We combine in situ and remote-sensing observations to inform a first-order glacier flow model used to estimate the relative contributions of sliding and internal deformation on dynamics. We find a significant increase in basal sliding rates between melt-seasons in the 1950s and those in the 1990s and 2010s and explore three process-based explanations for this anomalous behavior: (i) the glacier surface steepened over seven decades, maintaining flow-driving stresses despite sustained thinning; (ii) the formation of a proglacial lake after 1955 may support elevated basal water pressures; and (iii) subglacial topography may cause dynamic responses specific to Saskatchewan Glacier. Although further constraints are necessary to ascertain which processes are of greatest importance for Saskatchewan Glacier's dynamic evolution, this record provides a benchmark for studies of multi-decadal glacier dynamics.
Hospital epidemiologists, infection preventionists, and antimicrobial stewards are integral to the pandemic workforce. However, regardless of pandemic surge or postsurge conditions, their workload remains high due to constant vigilance for new variants, emerging data, and evolving public health guidance. We describe the factors that have led to burnout and suggest strategies to enhance resilience.
The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.
Artifacts, including ceramics, ground stone, and soil samples, as well as dental calculus, recovered from sites in the eastern North American central Plains were submitted to multiple laboratories for analysis of microbotanical remains. Direct accelerator mass spectrometer (AMS) dates of 361–197 cal BC provide evidence for the earliest use of maize (Zea mays ssp. mays) in this region. Squash (Cucurbita sp.), wild rice (cf. Zizania spp.), and palm (Arecaceae sp.) microremains were also found. This research adds to the growing evidence of the importance of microbotanical analysis in documenting plant use and in the identification of early maize. The combined data on early maize from the eastern Plains adds to our understanding of the timing and dispersal of this crop out of the American Southwest. Alternative explanations for the adoption and early use of maize by eastern central Plains communities include its value as a secondary resource, as an addition to an existing farming strategy, or as a component of Middle Woodland rituals.
OBJECTIVES/GOALS: Adolescents with congenital heart defects (CHD) have an elevated risk for future cardiovascular events, but information about their risk for e-cigarette use (“vaping”) is unknown. This study aims to present preliminary findings on gender differences in the association of impulsive behavior and vaping susceptibility from an ongoing investigation. METHODS/STUDY POPULATION: Adolescents with CHD (12-18 years; N=63) reported their vaping susceptibility and completed subjective (UPPS-P)/objective (Iowa Gambling Task; IGT) assessments of impulsive behavior previously associated with tobacco use. The UPPS-P includes 5 facets: 1) negative urgency (impulsivity under negative emotions), 2) positive urgency (impulsivity under positive emotions), 3) lack of premeditation (acting without thinking), 4) lack of perseverance (inability to focus), and 5) sensation seeking (seeking thrilling experiences). The IGT is a computerized task that creates conflict between immediate reward and delayed punishment via selections from advantageous/disadvantageous card decks. Linear regressions stratified by gender determined associations between vaping susceptibility and impulsivity. RESULTS/ANTICIPATED RESULTS: Nearly 30% (29.7%) of adolescents with CHD were susceptible to vaping. Negative urgency was associated with vaping susceptibility among females (Î² = 0.44, p = .035) but not males (Î² = 0.25, p = .128). Positive urgency was associated with vaping susceptibility among males (Î² = 0.37, p = .021) and trended toward significance among females (Î² = 0.40, p = .058). Lack of premeditation was associated with vaping susceptibility among males (Î² = 0.36, p = .025) but not females (Î² = 0.15, p = .490). The association between lack of perseverance and vaping susceptibility trended toward significance among males (Î² = 0.30, p = .064) but not females (Î² = -0.18, p = .413). IGT performance was not associated with susceptibility to vaping among either gender. UPPS-P facets and IGT performance were not significantly correlated. DISCUSSION/SIGNIFICANCE: The association of impulsivity and vaping susceptibility appears to be characterized by emotion-based rash action (positive/negative urgency) for females and by decreased conscientiousness (lack of premeditation/perseverance) for males. If replicated, the findings have implications for assessment of vaping risk and tailored intervention.
Racial and ethnic groups in the USA differ in the prevalence of posttraumatic stress disorder (PTSD). Recent research however has not observed consistent racial/ethnic differences in posttraumatic stress in the early aftermath of trauma, suggesting that such differences in chronic PTSD rates may be related to differences in recovery over time.
As part of the multisite, longitudinal AURORA study, we investigated racial/ethnic differences in PTSD and related outcomes within 3 months after trauma. Participants (n = 930) were recruited from emergency departments across the USA and provided periodic (2 weeks, 8 weeks, and 3 months after trauma) self-report assessments of PTSD, depression, dissociation, anxiety, and resilience. Linear models were completed to investigate racial/ethnic differences in posttraumatic dysfunction with subsequent follow-up models assessing potential effects of prior life stressors.
Racial/ethnic groups did not differ in symptoms over time; however, Black participants showed reduced posttraumatic depression and anxiety symptoms overall compared to Hispanic participants and White participants. Racial/ethnic differences were not attenuated after accounting for differences in sociodemographic factors. However, racial/ethnic differences in depression and anxiety were no longer significant after accounting for greater prior trauma exposure and childhood emotional abuse in White participants.
The present findings suggest prior differences in previous trauma exposure partially mediate the observed racial/ethnic differences in posttraumatic depression and anxiety symptoms following a recent trauma. Our findings further demonstrate that racial/ethnic groups show similar rates of symptom recovery over time. Future work utilizing longer time-scale data is needed to elucidate potential racial/ethnic differences in long-term symptom trajectories.
Monoclonal antibody therapeutics to treat coronavirus disease (COVID-19) have been authorized by the US Food and Drug Administration under Emergency Use Authorization (EUA). Many barriers exist when deploying a novel therapeutic during an ongoing pandemic, and it is critical to assess the needs of incorporating monoclonal antibody infusions into pandemic response activities. We examined the monoclonal antibody infusion site process during the COVID-19 pandemic and conducted a descriptive analysis using data from 3 sites at medical centers in the United States supported by the National Disaster Medical System. Monoclonal antibody implementation success factors included engagement with local medical providers, therapy batch preparation, placing the infusion center in proximity to emergency services, and creating procedures resilient to EUA changes. Infusion process challenges included confirming patient severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity, strained staff, scheduling, and pharmacy coordination. Infusion sites are effective when integrated into pre-existing pandemic response ecosystems and can be implemented with limited staff and physical resources.
To evaluate the impact of fetal haemodynamics on surgical and neurodevelopmental outcomes in severe Ebstein anomaly and tricuspid valve dysplasia.
Thirty-four fetuses with Ebstein anomaly/tricuspid valve dysplasia were referred from 2013 to 2019 for fetal echocardiography and clinical management. Nineteen fetuses with Ebstein anomaly/tricuspid valve dysplasia and 30 controls underwent cardiovascular magnetic resonance to quantify the fetal blood flow and to calculate cerebral oxygen delivery (cDO2) and consumption (cVO2). The 3D steady-state free precession acquisition was used to measure fetal brain volume. Surgical outcome, brain MRI, and neurodevelopmental follow-up were reviewed.
Twenty-six fetuses were live born (76%) and survival (65%) at a mean follow-up of 4 years. Nine fetuses had a brain MRI before discharge, and all had clinically silent injuries and volume loss. At 18 months, five single-ventricle patients had a neurodevelopmental delay in cognition and language (mean percentile: 11th), with gross-motor skills more affected than fine-motor skills (mean percentiles: 4th and 34th). Fetuses with Ebstein anomaly/tricuspid valve dysplasia had smaller brains, lower combined ventricular output, ascending aorta, superior caval vien and umbilical vein flows, lower oxygen saturation in ascending aorta and superior caval vien, lower cDO2 and cVO2 (p < 0.05). Superior caval vien/combined ventricular output and descending aorta/combined ventricular output ratios were lower in fetuses with circular shunt (p < 0.05). Fetuses requiring the Starnes procedure tended to have smaller brains, lower combined ventricular output, superior caval vien, descending aorta, and umbilical vein flows.
All patients with Ebstein anomaly/tricuspid valve dysplasia are at high risk of neurodevelopmental delay and warrant follow-up. Fetal cardiovascular magnetic resonance revealed impaired brain growth with diminished cerebral blood flow and cDO2, the extenting dependent on the severity of the haemodynamic compromise.
Theories of early cooperation in human society often draw from a small sample of ethnographic studies of surviving populations of hunter–gatherers, most of which are now sedentary. Borneo hunter–gatherers (Punan, Penan) have seldom figured in comparative research because of a decades-old controversy about whether they are the descendants of farmers who adopted a hunting and gathering way of life. In 2018 we began an ethnographic study of a group of still-nomadic hunter–gatherers who call themselves Punan Batu (Cave Punan). Our genetic analysis clearly indicates that they are very unlikely to be the descendants of neighbouring agriculturalists. They also preserve a song language that is unrelated to other languages of Borneo. Dispersed travelling groups of Punan Batu with fluid membership use message sticks to stay in contact, co-operate and share resources as they journey between rock shelters and forest camps. Message sticks were once widespread among nomadic Punan in Borneo, but have largely disappeared in sedentary Punan villages. Thus the small community of Punan Batu offers a rare glimpse of a hunting and gathering way of life that was once widespread in the forests of Borneo, where prosocial behaviour extended beyond the face-to-face community, facilitating successful collective adaptation to the diverse resources of Borneo's forests.
Both dendrochronology and radiocarbon (14C) dating have their roots back in the early to mid-1900s. Although they were independently developed, they began to intertwine in the 1950s when the founder of dendrochronology, A. E. Douglass, provided dated wood samples for Willard Libby to test his emerging 14C methods. Since this early connection, absolutely dated tree-rings have been key to calibration of the Holocene portion of the 14C timescale. In turn, 14C dating of non-calendar-dated tree-rings has served to place those samples more precisely in time, advance development of long tree-ring chronologies, and bring higher resolution to earlier portions of the 14C calibration curve. Together these methods continue to shape and improve chronological frameworks across the globe, answering questions in archaeology, history, paleoclimatology, geochronology, and ocean, atmosphere, and solar sciences.
This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology.
A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors.
Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few.
This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.
Seed retention, and ultimately seed shatter, are extremely important for the efficacy of harvest weed seed control (HWSC) and are likely influenced by various agroecological and environmental factors. Field studies investigated seed-shattering phenology of 22 weed species across three soybean [Glycine max (L.) Merr.]-producing regions in the United States. We further evaluated the potential drivers of seed shatter in terms of weather conditions, growing degree days, and plant biomass. Based on the results, weather conditions had no consistent impact on weed seed shatter. However, there was a positive correlation between individual weed plant biomass and delayed weed seed–shattering rates during harvest. This work demonstrates that HWSC can potentially reduce weed seedbank inputs of plants that have escaped early-season management practices and retained seed through harvest. However, smaller individuals of plants within the same population that shatter seed before harvest pose a risk of escaping early-season management and HWSC.
Analysis of patterns of faulting and hydrogeology, stratigraphic and sedimentologic studies, and luminescence dating of aeolian deposits in China Lake basin provide new perspectives on the origins and development of Late Holocene dunes and sand ramps in the seismically active Indian Wells Valley of eastern California. Aeolian dune and sand sheet deposits were sourced from alluvial material derived from granitic rocks of the south-eastern Sierra Nevada and are concentrated in areas with sand-stabilizing phreatophyte vegetation influenced by high groundwater levels along the active oblique-normal Little Lake and Paxton Ranch faults, which locally form barriers to groundwater flow. Three episodes of sand accumulation are recognized (2.1 ± 0.1 to 2.0 ± 0.1 ka, 1.8 ± 0.2 to 1.6 ± 0.2 ka, and 1.2 ± 0.1 to 0.9 ± 0.1 ka) during conditions in which sediment supplied to the basin during periods of enhanced rainfall and runoff was subsequently reworked by wind into dunes and sand ramps at the transition to more arid periods. Understanding the role tectonics plays in influencing the hydrogeology of seismically active lake basins provides insights to accurately interpret landscape evolution and any inferences made on past hydroclimate variability in a region.
Recurrent acute otitis media is common in children. The preferred treatment measures for recurrent acute otitis media have a mixed evidence base. This study sought to assess baseline practice across ENT departments in England.
A national telephone survey of healthcare staff was conducted. Every ENT centre in England was contacted. A telephone script was used to ask about antibiotic and grommet use and duration in recurrent acute otitis media cases.
Ninety-six centres (74 per cent) provided complete information. Recurrent acute otitis media treatment across England by ENT departments varied. The antibiotic first- and second-line prophylaxis offered varies, with trimethoprim used in 33 centres and 29 centres not offering any antibiotics. The timing or choice about when to use grommets also varies, but 87 centres (91 per cent) offer grommet surgery at one stage.
The treatments received by children in England for recurrent acute otitis media vary by centre; collaborative research in this area is advised.
A single high-fat, high-carbohydrate meal (HFHC) results in elevated postprandial glucose (GLU), triglycerides (TAG) and metabolic load index (MLI; TAG (mg/dl) + GLU (mg/dl)) that contributes to chronic disease risk. While disease risk is higher in older adults (OA) compared to younger adults (YA), the acute effects of exercise on these outcomes in OA is understudied. Twelve YA (age 23.3 ± 3.9 yrs, n = 5 M/7 F) and 12 OA (age 67·7 ± 6.0 yrs, n = 8 M/4 F) visited the laboratory in random order to complete a HFHC with no exercise (NE) or acute exercise (EX) condition. EX was performed 12 hours prior to HFHC at an intensity of 65 % of maximal heart rate to expend 75 % of the kcals consumed in HFHC (Marie Callender’s Chocolate Satin Pie; 12 kcal/kgbw; 57 % fat, 37 % CHO). Blood samples were taken at 0, 30, 60, 90 minutes, and then every hour until 6 hours post-meal. TAG levels increased to a larger magnitude in OA (Δ∼61 ± 31 %) compared to YA (Δ∼37 ± 34 %, P < 0·001), which were attenuated in EX compared to NE (P < 0·05) independent of age. There was no difference in GLU between OA and YA after the HFM, however, EX had attenuated GLU independent of age (NE: Δ∼21 ± 26 %; EX: Δ∼12 ± 18 %, P = 0·027). MLI was significantly lower after EX compared to NE in OA and YA (P < 0·001). Pre-prandial EX reduced TAG, GLU and MLI post-HFHC independent of age.
Cricothyrotomy and chest needle decompression (NDC) have a high failure and complication rate. This article sought to determine whether paramedics can correctly identify the anatomical landmarks for cricothyrotomy and chest NDC.
A prospective study using human models was performed. Paramedics were partnered and requested to identify the location for cricothyrotomy and chest NDC (both mid-clavicular and anterior axillary sites) on each other. A board-certified or board-eligible emergency medicine physician timed the process and confirmed location accuracy. All data were collected de-identified. Descriptive analysis was performed on continuous data; chi-square was used for categorical data.
A total of 69 participants were recruited, with one excluded for incomplete data. The paramedics had a range of six to 38 (median 14) years of experience. There were 28 medical training officers (MTOs) and 41 field paramedics. Cricothyroidotomy location was correctly identified in 56 of 68 participants with a time to identification range of 2.0 to 38.2 (median 8.6) seconds. Chest NDC (mid-clavicular) location was correctly identified in 54 of 68 participants with a time to identification range of 3.4 to 25.0 (median 9.5) seconds. Chest NDC (anterior axillary) location was correctly identified in 43 of 68 participants with a time to identification range of 1.9 to 37.9 (median 9.6) seconds. Chi-square (2-tail) showed no difference between MTO and field paramedic in cricothyroidotomy site (P = .62), mid-clavicular chest NDC site (P = .21), or anterior axillary chest NDC site (P = .11). There was no difference in time to identification for any procedure between MTO and field paramedic.
Both MTOs and field paramedics were quick in identifying correct placement of cricothyroidotomy and chest NDC location sites. While time to identification was clinically acceptable, there was also a significant proportion that did not identify the correct landmarks.