To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Donation of one unit of whole blood or apheresis can be used to obtain red blood cell (RBC) units. For apheresis RBCs, a donor is connected to an apheresis machine and RBCs are separated from other constituents which are returned to the donor; this process may yield 2 units of RBCs or a single unit of RBCs, along with a unit of platelets and/or plasma. RBC units are stored in polyvinyl chloride bags with the plasticizer di-2-ethylhexylphthalate (DEHP) to maintain RBC membrane integrity during storage. Preservation includes an anticoagulant-preservative (A-P) solution, and the current additive solutions maintain pH and other parameters needed to allow RBC storage shelf life of 42 days . ABO typing and matching are required to avoid reactions due to mismatch (see Table 13.1).
With an annual growth in travel demand of about 5% globally, managing the environmental impact is a challenge. In 2019, the International Civil Aviation Organisation (ICAO) issued emission reduction targets, including well-to-wake greenhouse gas (GHG) emissions reduced at least 50% from 2005 levels by 2050. This discusses several technologies from an aircraft design perspective that can contribute to achieving these targets. One thing is certain: aircraft will look different in the future. The Transonic Truss-Braced Wing and Flying V configurations are promising significant efficiency improvements over conventional configurations. Electric propulsion, in various architectures, is becoming a feasible option for general aviation and commuter aircraft. It will be a growing field of aviation with zero-emissions flight and opportunities for special missions. Lastly, this paper discusses methods and design processes that include all relevant disciplines to ensure that the aircraft is optimised as a complete system. While empirical methods are essential for initial design, Multidisciplinary Design Optimisation (MDO) incorporates models and simulations integrated in an optimisation environment to capture critical trade-offs. Concurrent design places domain experts in one site to facilitate collaboration, interaction, and joint decision-making, and to ensure all disciplines are equally considered. It is supported by a Collaborative Design Facility (CDF), an information technology facility with connected hardware and software tools for design analysis.
Noonan syndrome is a genetic disorder characteried by short stature, typical facial features, developmental delay, and CHD. In this single-centre retrospective study, we analysed typical Noonan syndrome-related electrocardiographic features in 95 patients with clinically and molecularly confirmed Noonan syndrome. Typical Noonan syndrome-related electrocardiographic features are left axis deviation, small left precordial R-waves, large right precordial S-waves, abnormal Q-wave, and abnormal wide QRS complex. In this representative cohort, CHD was found in 59 patients (62.1%) and typical Noonan syndrome-related electrographic features in 60 patients (63.2%). The typical Noonan syndrome-related electrographic features were also increased over baseline in patients without CHD (41.7%). Of all 95 patients, left axis deviation was seen in 46.3%, small left precordial R-waves in 30.5%, large right precordial S-waves in 5.3%, and abnormal Q-wave and wide QRS complex in 2.1%. There was no significant difference in the frequency of the individual-specific electrographic features between the group with CHD and the group without CHD. However, there were significantly more patients with a small left precordial R-wave in the subgroup with pulmonary stenosis compared to patients without pulmonary stenosis. Conclusion: Specific Noonan syndrome-related electrographic features are frequently present in patients with Noonan syndrome, also in the absence of CHD. These results suggest that there may be a continuum of cardiac anomalies from overt CHD to milder abnormalities that are only seen on electrocardiogram.
Background: In the Erasmus MC University Medical Center, Rotterdam, the Netherlands, patients considered at risk for carrying highly resistant microorganisms (HRMO) are placed in isolation on admission, until tested negative for HRMO (ie, targeted screening). Patients without risk factors are not routinely screened (ie, nontargeted screening). However, nontargeted screening could identify patients colonized with HRMO missed by targeted screening. To determine the additional value of nontargeted screening, we compared the outcomes of the nontargeted screening approach with all available clinical cultures. Objective: We aim to identify patients colonized with HRMO, but missed by targeted screening, and to determine whether non-targeted screening has additional value. Methods: For the MOVE study, nontargeted admission and discharge cultures (nose and perianal) were obtained from randomly selected patients admitted to specific wards, regardless of HRMO risk factors. This study was part of a research initiative to identify the relation of a contaminated environment with the risk of becoming infected or colonized on a patient level. All bacteriological clinical samples positive for at least 1 HRMO from January 1, 2018, until August 31, 2019, were compared with the nontargeted screening samples. Samples were screened for methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) as well as highly resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus faecium, and Enterobacteriales. Broth enrichment was used for all cultures. Results: During the study period, 50,653 patients were admitted. 706 patients (1%) had a clinical sample positive for at least 1 HRMO during their hospital stay. 936 (1.8%) patients were included in the nontargeted screening for the MOVE study, and 40 patients were found to have at least 1 culture positive for HRMO (4.3%). Among these 40 patients, 28 were positive at admission and 12 were positive at discharge. Extended-spectrum β-lactamase (ESBL)–producing Enterobacteriales were most prevalent (n = 36, 90.0%) both at admission and discharge (n = 26 and n = 10, respectively). At admission, 1 patient was identified with MRSA and 1 patient was positive for vancomycin-resistant E. faecium (VRE). At discharge, 1 patient was identified with VRE and 1 had Verona Integron-encoded Metallo-β-lactamase (VIM)–positive P. aeruginosa. Conclusions: Our results show that the current targeted screening does not identify all HRMO carriers. Furthermore, patients who acquire an HRMO during admission are missed. The nontargeted screening identified 40 unknown carriers (4.3%). The limitations of the study are the restricted number of sample sites and the fact that we were unable to culture all patients. Therefore, it is likely that our study shows an underestimation of the true number of patients with HRMO.
Background: Studies have shown that patients colonized with highly resistant microorganisms (HRMO) contaminate the hospital environment, and that transmission from contaminated environments to patients occurs. In May 2018, the Erasmus MC University Medical Center, Rotterdam, moved from a hospital with mostly multiple-occupancy rooms to a new hospital with 100% single-patient rooms with private bathrooms. This move provided the unique opportunity to determine environmental contamination before the new hospital was open for admissions and thereafter and to compare the environmental contamination to the number of patients colonized with HRMO. Method: Environmental sampling took place twice in the old building and 12 times in the new building, from 2 weeks before to 15 months after relocating patients. At each moment, ~306 samples were taken from 13 locations (eg, nightstands, sinks) in 40 patient rooms. Samples were screened for Staphylococcus aureus (methicillin-susceptible [MSSA] and methicillin resistant [MRSA]) and highly resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus faecium, and Enterobacteriales. During the study period, January 1, 2018, until August 31, 2019, all clinical samples positive for HRMO were included. Results: Environmental sampling revealed that 29 of 724 (4.0%) locations were positive for HRMO in the old building, whereas 4 of 3,358 (0.1%) samples in the new building were positive for HRMO (P < .001). In the old building, 14 of 29 locations were positive for extended-spectrum β-lactamase (ESBL)–producing bacteria and 15 were positive for carbapenemase-producing bacteria. In the new building, 3 of 4 positive samples were positive for vancomycin-resistant E. faecium (VRE), 1 was positive for ESBL-producing K. pneumoniae. For both HRMO, no carriers were detected. In the old building, 145 of 12,256 adult patients (1.2%) had clinical samples positive for HRMO, compared to 561 of 38,397 (1.5%) in the new building, a small but significant increase (P = .02). Conclusions: The transition from mainly 2- and 4-person rooms to 100% single-patient rooms resulted in a significant decrease in environmental contamination, even though the number of patients colonized with HRMO slightly increased. No molecular typing to determine transfer from environment to patients and vice versa has yet been performed. Future sampling is needed to determine whether the low environmental contamination is a long-term effect of the transition to single rooms.
Background: Isolation precautions are recommended when caring for patients identified with highly resistant microorganisms (HRMOs). However, the direct costs of isolating patients are largely unknown. Therefore, we aimed to obtain detailed information on the daily direct costs associated with isolating patients identified with HRMO. Methods: This study was performed from November until December 2017 on a 12-bed surgical ward. This ward contained solely isolation rooms with an anteroom. The daily direct costs of isolation were based on three cost items: (1) additional personal protective equipment (PPE); measured by counting the consumption of empty packaging materials, (2) cleaning and disinfection of the isolation room; based on the costs of an outsourced cleaning company, and (3) additional workload for healthcare workers; based on literature and multiplied by the average gross hourly salary of nurses. A distinction was made between the costs for strict isolation, contact-plus isolation, and contact isolation. Results: During the study period, 26 patients were nursed in isolation because of HRMO carriage, resulting in a total of 304 isolation days (median 7 isolation days; range 1-44). Gloves were consumed the most and hair caps the least. The average daily direct costs of isolation were the least expensive for contact isolation, €28/$31, and the most expensive for strict isolation, €41/$47. Conclusions: By using a novel, easy method to estimate consumption of PPE, we conclude that the daily direct costs of isolating a patient, differs per type of isolation. Insight into the direct costs of isolation is of utmost importance when developing or revising policies.
Antimicrobial resistance is an urgent public health threat. Identifying trends in antimicrobial susceptibility can inform public health policy at the state and local levels.
To determine the ability of statewide antibiogram aggregation for public health surveillance to identify changes in antimicrobial resistance trends.
Facility-level trend analysis.
Crude and adjusted trend analyses of the susceptibility of Escherichia coli and Klebsiella pneumoniae to particular antibiotics, as reported by aggregated antibiograms, were examined from 2008 through 2018. Multivariable regression analyses via generalized linear mixed models were used to examine associations between hospital characteristics and trends of E. coli and K. pneumoniae susceptibility to ciprofloxacin and ceftriaxone.
E. coli and K. pneumoniae showed inverse trends in drug susceptibility over time. K. pneumoniae susceptibility to fluoroquinolones increased by 5% between 2008 and 2018 (P < .05). In contrast, E. coli susceptibility declined during the same period to ceftriaxone (6%), gentamicin (4%), and fluoroquinolones (4%) (P < .05). When compared to Boston hospitals, E. coli isolates from hospitals in other regions had a >4% higher proportion of susceptibility to ciprofloxacin and a >3% higher proportion of susceptibility to ceftriaxone (P < .05). Isolates of K. pneumoniae had higher susceptibility to ciprofloxacin (>3%) and ceftriaxone (>1.5%) in all regions when compared to Boston hospitals (P < .05).
Cumulative antibiograms can be used to monitor antimicrobial resistance, to discern regional and facility differences, and to detect changes in trends. Furthermore, because the number of years that hospitals contributed reports to the state-level aggregate had no significant influence on susceptibility trends, other states should not be discouraged by incomplete hospital compliance.
Nosocomial outbreaks due to multidrug-resistant microorganisms in rehabilitation centers have rarely been reported. We report an outbreak of extended-spectrum beta-lactamase (ESBL)–producing Klebsiella pneumoniae (ESBL-K. pneumoniae) on a single ward in a rehabilitation center in Rotterdam, The Netherlands.
A 40-bed ward of a rehabilitation center in the Netherlands.
In October 2016, 2 patients were found to be colonized by genetically indistinguishable ESBL-K. pneumoniae isolates. Therefore, an outbreak management team was installed, by whom a contact tracing plan was made. In addition to general outbreak measures, specific measures were formulated to allow continuation of the rehabilitation process. Also, environmental cultures were taken. Multiple-locus variable-number tandem-repeat analysis and amplification fragment-length polymorphism were used to determine strain relatedness. Selected isolates were subjected to whole-genome multilocus sequence typing.
The outbreak lasted 8 weeks. In total, 14 patients were colonized with an ESBL-K. pneumoniae, of whom 11 patients had an isolate belonging to sequence type 307. Overall, 163 environmental cultures were taken. Several sites of a household washing machine were repeatedly found to be contaminated with the outbreak strain. This machine was used to wash lifting slings and patient clothing contaminated with feces. The outbreak was contained after taking the machine temporarily out of service and implementing a reinforced and adapted protocol on the use of this machine.
We conclude that in this outbreak, the route of transmission of the outbreak strain via the household washing machine played a major role.
This chapter describes our changing views on psychopathology and our attempts to model it. In particular, it argues how, for a significant step forward in mental health research, we should acknowledge the complex nature of mental illness. We introduce an exciting new paradigm in the field of psychopathology: the network paradigm. We discuss the basics of network theory, its application to psychopathology and some future directions of where this avenue may take us.
Co-ingestion of almonds with carbohydrate prevents excessive increase in plasma glucose level (PGL), but information about the functional fraction is limited. Identifying the functional fraction is necessary to use almonds more efficiently in terms of controlling postprandial glycaemia after a high-carbohydrate meal. In the present study, we evaluated the effects of almond skin, oil, water-soluble fraction and water-insoluble fraction on both postprandial glycaemia and insulinaemia. The effect of almond skin was tested by comparing the effect of whole almonds with the effect of skinless almonds. Male ICR mice were administered dextrin and 4 g/kg body weight test samples. After the administration, 2-h postprandial changes in glycaemia and insulinaemia were measured. Oil was the only fraction being able to blunt postprandial glycaemia. Interestingly, when co-ingesting with dextrin, almond oil did not change the insulin level compared with the control but whole almonds or skinless almonds triggered a 4-fold increase in insulin level. The co-ingestion of whole almonds or skinless almonds similarly suppressed the PGL at 15 and 30 min (P < 0·05), which means almond skin has no effect on postprandial glycaemia. Neither soluble nor insoluble fractions lead to any significant changes in postprandial glycaemia and insulinaemia. In conclusion, oil is the main functional component accounting for the glycaemia-lowering effect without altering insulin level.
Despite significant research examining mental health in conflict-affected populations we do not yet have a comprehensive epidemiological model of how mental disorders are distributed, or which factors influence the epidemiology in these populations. We aim to derive prevalence estimates specific for region, age and sex of major depression, and PTSD in the general populations of areas exposed to conflict, whilst controlling for an extensive range of covariates.
A systematic review was conducted to identify epidemiological estimates of depression and PTSD in conflict-affected populations and potential predictors. We analyse data using Bayesian meta-regression techniques.
We identified 83 studies and a list of 34 potential predictors. The age-standardised pooled prevalence of PTSD was 12.9% (95% UI 6.9–22.9), and major depression 7.6% (95% UI 5.1–10.9) – markedly lower than estimated in previous research but over two-times higher than the mean prevalence estimated by the Global Burden of Disease Study [3.7% (95% UI 3.0–4.5) and 3.5% (95% UI 2.9–4.2) for anxiety disorders and MDD, respectively]. The age-patterns reveal sharp prevalence inclines in the childhood years. A number of ecological variables demonstrated associations with prevalence of both disorders. Symptom scales were shown to significantly overestimate prevalence of both disorders. Finding suggests higher prevalence of both disorders in females.
This study provides, for the first time, age-specific estimates of PTSD and depression prevalence adjusted for an extensive range of covariates and is a significant advancement on our current understanding of the epidemiology in conflict-affected populations.
Mental and substance use disorders are common and often persistent, with many emerging in early life. Compared to adult mental and substance use disorders, the global burden attributable to these disorders in children and youth has received relatively little attention.
Data from the Global Burden of Disease Study 2010 was used to investigate the burden of mental and substance disorders in children and youth aged 0–24 years. Burden was estimated in terms of disability-adjusted life years (DALYs), derived from the sum of years lived with disability (YLDs) and years of life lost (YLLs).
Globally, mental and substance use disorders are the leading cause of disability in children and youth, accounting for a quarter of all YLDs (54.2 million). In terms of DALYs, they ranked 6th with 55.5 million DALYs (5.7%) and rose to 5th when mortality burden of suicide was reattributed. While mental and substance use disorders were the leading cause of DALYs in high-income countries (HICs), they ranked 7th in low- and middle-income countries (LMICs) due to mortality attributable to infectious diseases.
Mental and substance use disorders are significant contributors to disease burden in children and youth across the globe. As reproductive health and the management of infectious diseases improves in LMICs, the proportion of disease burden in children and youth attributable to mental and substance use disorders will increase, necessitating a realignment of health services in these countries.
Mortality-associated burden of disease estimates from the Global Burden of Disease 2010 (GBD 2010) may erroneously lead to the interpretation that premature death in people with mental, neurological and substance use disorders (MNSDs) is inconsequential when evidence shows that people with MNSDs experience a significant reduction in life expectancy. We explore differences between cause-specific and excess mortality of MNSDs estimated by GBD 2010.
GBD 2010 cause-specific death estimates were produced using the International Classification of Diseases death-coding system. Excess mortality (all-cause) was estimated using natural history models. Additional mortality attributed to MNSDs as underlying causes but not captured through GBD 2010 methodology is quantified in the comparative risk assessments.
In GBD 2010, MNSDs were estimated to be directly responsible for 840 000 deaths compared with more than 13 million excess deaths using natural history models.
Numbers of excess deaths and attributable deaths clearly demonstrate the high degree of mortality associated with these disorders. There is substantial evidence pointing to potential causal pathways for this premature mortality with evidence-based interventions available to address this mortality. The life expectancy gap between persons with MNSDs and the general population is high and should be a focus for health systems reform.
Autism spectrum disorders (ASDs) are persistent disabling neurodevelopmental disorders clinically evident from early childhood. For the first time, the burden of ASDs has been estimated for the Global Burden of Disease Study 2010 (GBD 2010). The aims of this study were to develop global and regional prevalence models and estimate the global burden of disease of ASDs.
A systematic review was conducted for epidemiological data (prevalence, incidence, remission and mortality risk) of autistic disorder and other ASDs. Data were pooled using a Bayesian meta-regression approach while adjusting for between-study variance to derive prevalence models. Burden was calculated in terms of years lived with disability (YLDs) and disability-adjusted life-years (DALYs), which are reported here by world region for 1990 and 2010.
In 2010 there were an estimated 52 million cases of ASDs, equating to a prevalence of 7.6 per 1000 or one in 132 persons. After accounting for methodological variations, there was no clear evidence of a change in prevalence for autistic disorder or other ASDs between 1990 and 2010. Worldwide, there was little regional variation in the prevalence of ASDs. Globally, autistic disorders accounted for more than 58 DALYs per 100 000 population and other ASDs accounted for 53 DALYs per 100 000.
ASDs account for substantial health loss across the lifespan. Understanding the burden of ASDs is essential for effective policy making. An accurate epidemiological description of ASDs is needed to inform public health policy and to plan for education, housing and financial support services.
Despite their high prevalence, the global burden of anxiety disorders has never been calculated comprehensively. The new Global Burden of Disease (GBD) study has estimated burden due to morbidity and mortality caused by any anxiety disorder.
Prevalence was estimated using Bayesian meta-regression informed by data identified in a systematic review. Years of life lived with disability (YLDs) were calculated by multiplying prevalent cases by an average disability weight based on severity proportions (mild, moderate and severe). Disability-adjusted life years (DALYs) were then calculated and age standardized using global standard population figures. Estimates were also made for additional suicide mortality attributable to anxiety disorders. Findings are presented for YLDs, DALYs and attributable burden due to suicide for 21 world regions in 1990 and 2010.
Anxiety disorders were the sixth leading cause of disability, in terms of YLDs, in both high-income (HI) and low- and middle-income (LMI) countries. Globally, anxiety disorders accounted for 390 DALYs per 100 000 persons [95% uncertainty interval (UI) 191–371 DALYs per 100 000] in 2010, with no discernible change observed over time. Females accounted for about 65% of the DALYs caused by anxiety disorders, with the highest burden in both males and females experienced by those aged between 15 and 34 years. Although there was regional variation in prevalence, the overlap between uncertainty estimates means that substantive differences in burden between populations could not be identified.
Anxiety disorders are chronic, disabling conditions that are distributed across the globe. Future estimates of burden could be further improved by obtaining more representative data on severity state proportions.
The incidence of rabies in livestock is an important factor for estimating the economic impact of the disease, but obtaining reliable data is hindered by inadequate surveillance. In order to understand the contribution of livestock rabies to the overall burden of disease, the rabies incidence in cattle was investigated in detail for Turkey between 2008 and 2011. Data were compiled on cattle numbers, samples submitted for rabies diagnosis, vaccinated animals and positive rabies cases in animals for seven regions in Turkey. Rabies incidence in cattle fluctuated annually and differed between regions from 0·10 to 3·87 cases/100 000 animals. The positive influence of compensation schemes was observed. Livestock losses were conservatively estimated at around $250 000 international dollars per annum, although in areas where compensation schemes are not operating this could be an underestimate of the economic burden. Vaccination of cattle remains an option for disease prevention, although oral rabies vaccination through aerially distributed baits should be implemented to prevent the further spread of fox-mediated rabies, which could result in much greater economic costs.
We reviewed photographic images of fishes from depths of 381–2282 m in Marguerite Bay and 405–2007 m in the Amundsen Sea. Marguerite Bay fishes were 33% notothenioids and 67% non-notothenioids. Channichthyids (47%) and nototheniids (44%) were the most abundant notothenioids. The deep-living channichthyid Chionobathyscus dewitti (74%) and the nototheniid genus Trematomus (66%) were the most abundant taxa within these two families. The most abundant non-notothenioids were the macrourid Macrourus whitsoni (72%) and zoarcids (18%). Amundsen Sea fishes were 87% notothenioids and 13% non-notothenioids, the latter exclusively Macrourus whitsoni. Bathydraconids (38%) and artedidraconids (30%) were the most abundant notothenioids. We observed that Macrourus whitsoni was benthopelagic and benthic and infested by large ectoparasitic copepods. Juvenile (42 cm) Dissostichus mawsoni was not neutrally buoyant and resided on the substrate at 1277 m. Lepidonotothen squamifrons was seen near and on nests of eggs in early December. A Pogonophryne sp. from 2127 m was not a member of the deep-living unspotted P. albipinna group. Chionobathyscus dewitti inhabited the water column as well as the substrate. The pelagic zoarcid Melanostigma gelatinosum was documented in the water column a few metres above the substrate. The zoogeographic character of the Marguerite Bay fauna was West Antarctic or low-Antarctic and the Amundsen Sea was East Antarctic or high-Antarctic.
Summarizing the epidemiology of major depressive disorder (MDD) at a global level is complicated by significant heterogeneity in the data. The aim of this study is to present a global summary of the prevalence and incidence of MDD, accounting for sources of bias, and dealing with heterogeneity. Findings are informing MDD burden quantification in the Global Burden of Disease (GBD) 2010 Study.
A systematic review of prevalence and incidence of MDD was undertaken. Electronic databases Medline, PsycINFO and EMBASE were searched. Community-representative studies adhering to suitable diagnostic nomenclature were included. A meta-regression was conducted to explore sources of heterogeneity in prevalence and guide the stratification of data in a meta-analysis.
The literature search identified 116 prevalence and four incidence studies. Prevalence period, sex, year of study, depression subtype, survey instrument, age and region were significant determinants of prevalence, explaining 57.7% of the variability between studies. The global point prevalence of MDD, adjusting for methodological differences, was 4.7% (4.4–5.0%). The pooled annual incidence was 3.0% (2.4–3.8%), clearly at odds with the pooled prevalence estimates and the previously reported average duration of 30 weeks for an episode of MDD.
Our findings provide a comprehensive and up-to-date profile of the prevalence of MDD globally. Region and study methodology influenced the prevalence of MDD. This needs to be considered in the GBD 2010 study and in investigations into the ecological determinants of MDD. Good-quality estimates from low-/middle-income countries were sparse. More accurate data on incidence are also required.