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The boundary between services for children and adolescents and adults has been identified as problematic for young people with mental health problems.
To examine the use and cost of healthcare for young people engaged in mental healthcare before and after the child/adolescent and adult service boundary.
Data from 772 young people in seven European countries participating in the MILESTONE trial were analysed. We analysed and costed healthcare resources used in the 6-month period before and after the service boundary.
The proportion of young people engaging with healthcare services fell substantially after crossing the service boundary (associated costs €7761 pre-boundary v. €3376 post-boundary). Pre-boundary, the main cost driver was in-patient care (approximately 50%), whereas post-boundary costs were more evenly spread between services; cost reductions were correlated with pre-boundary in-patient care. Severity was associated with substantially higher costs pre- and post-boundary, and those who were engaged specifically with mental health services after the service boundary accrued the greatest healthcare costs post-service boundary.
Costs of healthcare are large in this population, but fall considerably after transition, particularly for those who were most severely ill. In part, this is likely to reflect improvement in the mental health of young people. However, qualitative evidence from the MILESTONE study suggests that lack of capacity in adult services and young people's disengagement with formal mental health services post-transition are contributing factors. Long-term data are needed to assess the adverse long-term effects on costs and health of this unmet need and disengagement.
Poor transition planning contributes to discontinuity of care at the child–adult mental health service boundary (SB), adversely affecting mental health outcomes in young people (YP). The aim of the study was to determine whether managed transition (MT) improves mental health outcomes of YP reaching the child/adolescent mental health service (CAMHS) boundary compared with usual care (UC).
A two-arm cluster-randomised trial (ISRCTN83240263 and NCT03013595) with clusters allocated 1:2 between MT and UC. Recruitment took place in 40 CAMHS (eight European countries) between October 2015 and December 2016. Eligible participants were CAMHS service users who were receiving treatment or had a diagnosed mental disorder, had an IQ ⩾ 70 and were within 1 year of reaching the SB. MT was a multi-component intervention that included CAMHS training, systematic identification of YP approaching SB, a structured assessment (Transition Readiness and Appropriateness Measure) and sharing of information between CAMHS and adult mental health services. The primary outcome was HoNOSCA (Health of the Nation Outcome Scale for Children and Adolescents) score 15-months post-entry to the trial.
The mean difference in HoNOSCA scores between the MT and UC arms at 15 months was −1.11 points (95% confidence interval −2.07 to −0.14, p = 0.03). The cost of delivering the intervention was relatively modest (€17–€65 per service user).
MT led to improved mental health of YP after the SB but the magnitude of the effect was small. The intervention can be implemented at low cost and form part of planned and purposeful transitional care.
Measurements in the infrared wavelength domain allow direct assessment of the physical state and energy balance of cool matter in space, enabling the detailed study of the processes that govern the formation and evolution of stars and planetary systems in galaxies over cosmic time. Previous infrared missions revealed a great deal about the obscured Universe, but were hampered by limited sensitivity.
SPICA takes the next step in infrared observational capability by combining a large 2.5-meter diameter telescope, cooled to below 8 K, with instruments employing ultra-sensitive detectors. A combination of passive cooling and mechanical coolers will be used to cool both the telescope and the instruments. With mechanical coolers the mission lifetime is not limited by the supply of cryogen. With the combination of low telescope background and instruments with state-of-the-art detectors SPICA provides a huge advance on the capabilities of previous missions.
SPICA instruments offer spectral resolving power ranging from R ~50 through 11 000 in the 17–230 μm domain and R ~28.000 spectroscopy between 12 and 18 μm. SPICA will provide efficient 30–37 μm broad band mapping, and small field spectroscopic and polarimetric imaging at 100, 200 and 350 μm. SPICA will provide infrared spectroscopy with an unprecedented sensitivity of ~5 × 10−20 W m−2 (5σ/1 h)—over two orders of magnitude improvement over what earlier missions. This exceptional performance leap, will open entirely new domains in infrared astronomy; galaxy evolution and metal production over cosmic time, dust formation and evolution from very early epochs onwards, the formation history of planetary systems.
We investigated the Quaternary lithological succession and faunas in a borehole near Moriaanshoofd (Province of Zeeland, SW Netherlands), in order to improve our understanding of the depositional context of classical Gelasian mammal faunas from the region. The fossils mostly derive from the base of a fossil-rich interval between 31 m and 36.5 m below the surface, that was initially interpreted as a Middle or Late Pleistocene interglacial marine unit, but turned out to be a Late Quaternary fluvial unit with large amounts of reworked fossils and sediments. Eocene mollusc taxa pinpoint Flanders (Belgium) as the source region for this river. Within the base of this paleo-Schelde River fossil material of various stratigraphic provenance became incorporated.
The involvement of adrenocortical and thyroid hormones in the pathogenesis of ketosis as well as the ovarian consequences of this metabolic disorder were studied in ≥2 parity cows (n=199) in 3 large scale dairy herds. To compare the plasma / serum concentrations of certain hormones [Cortisol, thyroxin (T4), triiodo-thyronine (T3), insulin, isulin-like growth factor-1 (IGF-l)J and metabolites [glucose (G), acetoacetic acid (ACAC), βOH-butyrate (BHB), non-esterified fatty acid (NEFA), trigliceride (TG), total cholesterol (TCh)J, and the activity of aspartate aminotransferase (AST), blood samples were taken 1 to 3 days after calving and again at 7-day intervals on four other occasions. The ACTH-challenged Cortisol responsiveness and the TRH-induced T4/T3 increase were determined between days 1 to 3 and again between days 28 to 35. The resumption of ovarian cyclicity was followed up by individual progesterone (P4) profiles based on milk samples taken 3 times a week for about 80 to 85 days postpartum. A concentration of 1 mmol/l of BHB level was estimated as a border between hyper- (>1 mmol/l) and normal ketonaemic (<1 mmol/l) conditions. 5 different ketone patterns were distinguished: (1) non-ketotic (n=98; normal ketonaemia in all samples), (2) early type ketosis (n=45; hyperketonemia was detected only in the first week after calving), (3) late type (lacta-tional) ketosis (n=11; after a normal ketonaemic period increasing hyperketonaemia was detected in the 5th, or in the 4th and 5th weeks), (4) temporary ketosis (n=ll; hyperketonaemia was detected for 1-2 weeks in the 2nd and 3rd or in the 3rd and 4th weeks); (5) long-lasting ketosis (n=34; hyperketonaemia had been detected since calving for 4 to 5 weeks or until death or emergency slaughtering). Simultaneously with the hyperketonaemic stage increased NEFA, ACAC, depressed TCh, glucose and decreased insulin, IGF-1, T4 and T3 concentrations were detected in almost all the cases. Obvious metabolic and endocrine alterations were found, however, only in long-lasting ketosis. The TRH-stimulated T4 and T3 responses remained almost unaffected proving intact thyroid function in early and late type as well as in temporary ketosis. Depressed thyroid response and delayed onset of cyclic ovarian function were detected only in cases of long-lasting ketosis. The cows characterized by lower than normal (< mean-SD of non-ketotic cows) ACTH-stimulated cortisol response on days 1-3 after calving showed poorer chancefor spontaneous recovery. There was a significant negative correlation between the IGF-1 level in the 1st week after calving and the duration of the postpartum acyclic period. In late type (lactational) ketosis the cessation of ovarian cyclicity was the most characteristic genital malfunction.
The consequences of peri-parturient Monensin administration were studied in two dairy herds in ≥ 2 parity HF cows (1) calving in moderate body condition (score, BCS: 3.25-3.75) and producing ≥8500 kg FCM in the previous lactation (Herd K), as well as (2) in those being overfed before calving (BCS: ≥3.75), but producing less milk (5-8000 kg FCM) (Herd S). In both herds on days 249-256 of gestation half of the cows received an intraruminal constant release capsule of Monensin (Rumensin® capsule, ELANCO) (Monensin-K and Monensin-S cows), the others remained untreated controls (Control-K and Control-S cows). Blood samples were taken on day 1-3 after calving and again 4 times with 7 days intervals to assay certain hormones and metabolites. On days 1-3 and again on days 28-35 also the ACTH induced Cortisol response and TRH induced T4/T3 responses were determined. The resumption of ovarian cyclicity was followed by milk progesterone profiles. In the first 10 weeks after calving the milk production of Monensin-K cows (n=13) did not differ from that of Control-K cows (n=14). The cows lost their body weight continuously in the first 10 weeks of lactation in Herd S, whereas only in the first 5 weeks in Herd K. Monensin only slightly influenced the degree of weight loss (on both farms), and the circulating leptin level (determined only in Herd S). Significantly lower insulin, IGF-1, T4, T3, glucose and cholesterol levels as well as less elevated βOH-butyrate and non-esterified fatty acid concentrations were seen in Control-S (n=13) than in Monensin-S (n=ll) cows, first of all in the first two weeks after calving. These ionophor-related differences were less obvious or disappeared in Herd-K. Monensin shortened the postpartum acyclic and anestrous periods as well as the calving to re-conception interval but this effect was significant only in the Herd S.
The postpartum changes in plasma leptin levels of dairy cows ovulated within 35 days after calving were compared to of those with delayed onset of cyclicity in two experiments. The cows were sampled for leptin, insulin, IGF-1, thyroid hormones (T4, T3, rT3), Cortisol and also for some metabolites (glucose, NEFA, BHB and TCH) on day 1-3 after calving and again four times 7 days apart (Exp. 1), or in weeks 1, 2, 3, 5 and 10 postpartum (Exp. 2). In Exp. 1 also the standard low dose ACTH-induced Cortisol response and TRH-stimulated T4/T3 responses were determined on days 1-3 and 28-35. In cows of Exp. 1 the leptin level varied within a wide range with a mean of about 4 ng/ml HE in the first samples. Up to week 5 it remained unchanged in cows ovulated within day 35 but reduced in those with delayed onset of cyclicity, resulting in significant difference between the two group means.
In cows of Exp. 2 the week 1 leptin levels were lower and less variable than that of Exp. 1. In weeks 2 and 3 a slightly increasing tendency of leptin pattern was seen in cows resuming their ovarian cyclicity within 35 days whereas in those with delayed onset of cyclicity the leptin level remained unchanged. Up to week 5 this tendency resulted in exactly the same leptin values as seen in Exp. 1 with significant differences between the group means in both of the weeks 5 and 10. It was concluded that the plasma leptin concentration in postpartum dairy cows may interfere with resumption of cyclic ovarian function, but its influence may be only permissive (e.g. a minimal concentration above a supposed threshold seems to be the prerequisite of the onset of cyclicity)
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