Lytham Hospital

AIM: To compare quality of life, level of disability, and caregiver burden in 3 groups of people with Parkinson disease (PD): those with mild cognitive impairment (PD-MCI), those with dementia (PDD), and those with no cognitive impairment (PD-NC). BACKGROUND: Although the cognitive profile of those with PD-MCI and PDD has been well described, little is known about the personal and clinical impact of cognitive impairment and its impact on caregivers. METHOD: Quality of life and disability were measured in 3 groups of participants with PD (PD-NC, n=54; PD-MCI, n=48; and PDD, n=25). The PD-MCI group was classified using Movement Disorder Society Task Force consensus criteria. Caregivers (n=102) in the 3 groups were assessed using the Zarit Burden Inventory. RESULTS: Both quality of life and caregiver burden were similar in the 2 groups without dementia but were significantly different in those with PDD. In contrast, global disability was progressively greater as cognition declined across the 3 PD groups: PD-NC<PD-MCI<PDD and on the Activities of Daily Living scale a step up in impairment was seen with the presence of any cognitive impairment. CONCLUSIONS: The presence of dementia significantly increases caregiver burden and decreases quality of life. However, even mild levels of cognitive impairment increase disability and overall functional impairment progresses in tandem with cognitive decline.

Neuropsychiatric symptoms commonly complicate Parkinson's disease (PD), however the presence of such symptoms in mild cognitive impairment (PD-MCI) specifically has not yet been well described. The objective of this study was to examine and compare the prevalence and profile of neuropsychiatric symptoms in patients with PD-MCI (n = 48) to those with PD and no cognitive impairment (PD-NC, n = 54) and to those with dementia in PD (PDD, n = 25). PD-MCI and PDD were defined using specific consensus criteria, and neuropsychiatric symptoms were assessed with the 12-item Neuropsychiatric Inventory (NPI). Self-rated apathy, depression, and anxiety rating scales were also administered. Over 79% of all participants reported at least one neuropsychiatric symptom in the past month. The proportion in each group who had total NPI scores of ≥4 ("clinically significant") was as follows: PD-NC, 64.8%; PD-MCI, 62%; PDD 76%. Apathy was reported in almost 50% of those with PD-MCI and PDD, and it was an important neuropsychiatric symptom differentiating PD-MCI from PD-NC. Psychosis (hallucinations and delusions) increased from 12.9% in PD-NC group; 16.7% in PD-MCI group; and 48% in PDD group. Identifying neuropsychiatric symptoms in PD-MCI may have implications for ascertaining conversion to dementia in PD.

Abstract This study investigates the role of human capital and political development in determining the magnitude of the effects of foreign direct investment ( FDI ) on growth for a panel of 61 transition and developing countries for the period 1989 to 2013. A baseline growth model incorporating these variables is tested and then extended to include FDI interaction effects with human capital (measured using secondary school enrollment data) and political development (based on Economist Intelligence Unit Democracy Index scores). These growth interaction effects between FDI and human capital vary according to regime type. Political development in conjunction with FDI appears to suppress the effects of FDI on growth in authoritarian countries while enhancing them in hybrid democracies. For more democratic countries, domestic investment is a more important driver of growth. The effects of FDI on growth in the ten transition economies included in the sample data set are found to be insignificant. Although this result might seem to differ from a priori expectations, it is in line with the findings of most earlier studies that cover the period up to 2004. The paper also provides no strong evidence that a critical threshold of human capital is required to generate beneficial spillover growth effects from inflows of FDI . The paper provides new and more detailed insights into the effects of FDI on growth with particular respect to human capital and political regime covering a large number of transition and developing countries based on an up‐to‐date data set covering a 25‐year period to 2013. © 2016 Wiley Periodicals, Inc .

BackgroundAggressive, agitated or violent behaviour due to psychosis constitutes an emergency psychiatric treatment where fast‐acting interventions are required. Risperidone is a widely accessible antipsychotic that can be used to manage psychosis‐induced aggression or agitation. ObjectivesTo examine whether oral risperidone alone is an effective treatment for psychosis‐induced aggression or agitation. Search methodsWe searched the Cochrane Schizophrenia Group's Study‐Based Register of Trials (up to April 2017); this register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings. There are no language, date, document type, or publication status limitations for inclusion of records into the register. Selection criteriaRandomised controlled trials (RCTs) comparing rapid use of risperidone and other drugs, combinations of drugs or placebo for people exhibiting aggression or agitation (or both) thought to be due to psychosis. Data collection and analysisWe independently inspected all citations from searches, identified relevant abstracts, and independently extracted data from all included studies. For binary data we calculated risk ratio (RR) and for continuous data we calculated mean difference (MD), all with 95% confidence intervals (CI) and used a fixed‐effect model. We assessed risk of bias for the included studies and used the GRADE approach to produce a ’Summary of findings’ tables. Main resultsThe review now contains data from nine trials (total n = 582) reporting on five comparisons. Due to risk of bias, small size of trials, indirectness of outcome measures and a paucity of investigated and reported 'pragmatic' outcomes, evidence was graded as very‐low quality. None of the included studies provided useable data on our primary outcome 'tranquillisation or asleep' by 30 minutes, repeated need for tranquillisation or any economic outcomes. Data were available for our other main outcomes of agitation or aggression, needing restraint, and incidence of adverse effects. Risperidone versus haloperidol (up to 24 hours follow‐up) For the outcome, specific behaviour ‐ agitation, no clear difference was found between risperidone and haloperidol in terms of efficacy, measured as at least 50% reduction in the Positive and Negative Syndrome Scale ‐ Psychotic Agitation Sub‐score (PANSS‐PAS) (RR 1.04, 95% CI 0.86 to 1.26; participants = 124; studies = 1; very low‐quality evidence) and no effect was observed for need to use restraints (RR 2.00, 95% CI 0.43 to 9.21; participants = 28; studies = 1; very low‐quality evidence). Incidence of adverse effects was similar between treatment groups (RR 0.94, 95% CI 0.54 to 1.66; participants = 124; studies = 1; very low‐quality evidence). Risperidone versus olanzapine One small trial (n = 29) reported useable data for the comparison risperidone versus olanzapine. No effect was observed for agitation measured as PANSS‐PAS endpoint score at two hours (MD 2.50, 95% CI ‐2.46 to 7.46; very low‐quality evidence); need to use restraints at four days (RR 1.43, 95% CI 0.39 to 5.28; very‐low quality evidence); specific movement disorders measured as Behavioural Activity Rating Scale (BARS) endpoint score at four days (MD 0.20, 95% CI ‐0.43 to 0.83; very low‐quality evidence). Risperidone versus quetiapine One trial reported (n = 40) useable data for the comparison risperidone versus quetiapine. Aggression was measured using the Modified Overt Aggression Scale (MOAS) endpoint score at two weeks. A clear difference, favouring quetiapine was observed (MD 1.80, 95% CI 0.20 to 3.40; very‐low quality evidence). No evidence of a difference between treatment groups could be observed for incidence of akathisia after 24 hours (RR 1.67, 95% CI 0.46 to 6.06; very low‐quality evidence). Two participants allocated to risperidone and one allocated to quetiapine experienced myocardial ischaemia during the trial. Risperidone versus risperidone + oxcarbazepine One trial (n = 68) measured agitation using the Positive and Negative Syndrome Scale ‐ Excited Component.(PANSS‐EC) endpoint score and found a clear difference, favouring the combination treatment at one week (MD 2.70, 95% CI 0.42 to 4.98; very low‐quality evidence), but no effect was observed for global state using Clinical Global Impression ‐ Improvement (CGI‐I) endpoint score at one week (MD ‐0.20, 95% CI ‐0.61 to 0.21; very‐low quality evidence). Incidence of extrapyramidal symptoms after 24 hours was similar between treatment groups (RR 1.59, 95% CI 0.49 to 5.14; very‐low quality evidence). Risperidone versus risperidone + valproic acid Two trials compared risperidone with a combination of risperidone plus valproic acid. No clear differences between the treatment groups were observed for aggression (MOAS endpoint score at three days: MD 1.07, 95% CI ‐0.20 to 2.34; participants = 54; studies = 1; very low‐quality evidence) or incidence of akathisia after 24 hours: RR 0.75, 95% CI 0.28 to 2.03; participants = 122; studies = 2; very low‐quality evidence). Authors' conclusionsOverall, results for the main outcomes show no real effect for risperidone. The only data available for use in this review are from nine under‐sampled trials and the evidence available is of very low quality. This casts uncertainty on the role of risperidone in rapid tranquillisation for people with psychosis‐induced aggression. High‐quality pragmatic RCTs are feasible and are needed before clear recommendations can be drawn on the use of risperidone for psychosis‐induced aggression or agitation.

Cytotaxonomic identifications of larvae of members of the Simulium damnosum Theobald (Diptera: Simuliidae) complex collected in forest zones of southeast Ghana and southwest Togo between 1977 and 1996 showed that the Djodji form of Simulium sanctipauli Vajime & Dunbar, a vector of onchocerciasis, was eliminated in 1988 by larvicide operations conducted by the World Health Organization (WHO) Onchocerciasis Control Programme (OCP) in West Africa. No members of the form were identified amongst 997 larvae collected up to 8 years after systematic control operations began in February 1988. The results are discussed in relation to estimates of the numbers of samples required to certify elimination and the possibility that other members of the S. damnosum complex were also eliminated by the OCP.

Background: We examined the responsiveness of the Manchester Chronic Obstructive Pulmonary Disease (COPD) Fatigue Scale (MCFS) in patients with COPD following 8 weeks of pulmonary rehabilitation (PR). Methods: Patients ( n = 273) with clinically stable COPD completed 8 weeks of outpatient multidisciplinary PR, comprising 2 h (1 h exercise and 1 h education) weekly. Anxiety, exercise capacity, quality of life, dyspnea, fatigue were measured pre- and post-PR, utilizing the Anxiety Inventory for Respiratory Disease (AIR), Incremental Shuttle Walk Test (ISWT), St. George’s Respiratory Questionnaire (SGRQ), and modified Medical Research Council (mMRC) scale and MCFS, respectively. Results: The mean (SD) age of participants was 72 (8) years, and 50% were women. Total MCFS score fell after PR mean (95% confidence interval) −4.89 (–7.90 to −3.79) as did domain scores: physical −1.89 (–2.33 to −1.46), cognition −1.37 (–1.65 to −1.09), and psychosocial −1.62 (–2.00 to −1.62). Total MCFS effect size (ES) was 0.55; and for domains, physical was 0.52, cognition was 0.59, and psychosocial was 0.51. The ES for AIR was 0.30, mMRC was 0.38, SGRQ was 0.66, and ISWT was 1.19. MCFS changes correlated with changes in both SGRQ ( p &lt; 0.002) and AIR ( p &lt; 0.004), but not ISWT ( p = 0.30) or mMRC ( p = 0.18). The AIR, SGRQ, mMRC, and ISWT all improved after PR (all, p &lt; 0.001). Conclusion: The MCFS scale is a valid and responsive scale to measure fatigue in patients with COPD after pulmonary rehabilitation.

This study was requested to investigate the relative strengths of two different ward arrangements. Both wards were psychiatric assessment wards for people over the age of 65 and both were mixed sex wards. The major focus was to examine if the separation of cognitively impaired (CI) and functional clients on an elderly assessment ward had benefits in terms of client and staff satisfaction. The study involved 192 hours of observation, following four clients on each ward for 24-hours. Results indicate that the split ward and the mixed ward differ qualitatively and that in terms of user and staff satisfaction the split model is preferable. Implications for service development and future research are also discussed.

Purpose This paper is an overview of aero gas turbine engine starting systems and discusses the system design considerations and integration with other aircraft systems. Design/methodology/approach Review of a range of recent publications on the subject, aiming to provide an introduction to modern aero gas turbine engine starting systems. Findings Provides basic information on starter types and their limitations, and why some starter types are more favoured in modern installations. The effects of altitude and temperature are discussed which may not be initially considered as variables affecting aero start systems. Originality/value This paper provides further information on the starting systems of modern aero gas turbines and the considerations associated with integration and efficiency.

Abstract Most, if not all, of the vehicle systems need some means of measuring and monitoring of their performance, as well as the implementation of control functions. This chapter will describe how this function evolved from many individual control units, often based on relay logic into integrated software‐driven architectures, performing many sophisticated and safety critical functions. The development of the system through a range of military and commercial aircraft types will be described and the examples given. Descriptions of the input output interfacing, data bus types, processing and memory architectures, and total system architectures will also be provided.

The death of a child is a devastating event. Families experience profound grief and loss immediately following the death, and this remains and evolves as time progresses. In this, the second in a series, we discuss the importance of longer term bereavement care and how continuing contact with healthcare can be navigated. As bereaved parents who are also doctors, we again share our experiences. The complex nature of parenting, supporting siblings or managing a pregnancy after loss are explored, and we look at the involvement of bereaved parents in developing bereavement services.

The death of a child is a complex and hugely significant time for a family and community. Sophisticated but sensitive management by clinicians can have both short-term and long-term impacts on how families process the death. There is a paucity of guidance for optimal child bereavement care. A description of the child death review process including key legalities is provided here, and other essential aspects such as memory making, cultural aspects and sibling involvement are explored. Useful agencies and resources are also detailed. We, as both clinicians and bereaved parents, can uniquely provide an overview of the logistics of managing such a challenging event and highlight important subtleties in communication. We attempt, using our own experiences, to provide a framework and best inform future practice.

Abstract Invasive group A streptococcal (GAS) disease is uncommon but carries a high case-fatality rate relative to other infectious diseases. Given the ubiquity of mild GAS infections, it remains unclear why healthy individuals will occasionally develop life-threatening infections, raising the possibility of host genetic predisposition. Here, we present the results of a case-control study including 43 invasive GAS cases and 1,540 controls. Using HLA imputation and linear mixed-models, we find each copy of the HLA-DQA1 *01:03 allele associates with a two-fold increased risk of disease (odds ratio 2.3, 95% confidence interval 1.3-4.4, P =0.009), an association which persists with classical HLA typing of a subset of cases and analysis with an alternative large control dataset with validated HLA data. Moreover, we propose the association is driven by the allele itself rather than the background haplotype. Overall this finding provides impetus for further investigation of the immunogenetic basis of this devastating bacterial disease.

Abstract The economic crisis has exacted a heavy price on labour markets throughout the world and raised serious questions about the ability of the flexicurity policies to deal with the consequences. In this regard, the experience of Poland with its more flexible approach and relative success in weathering the storm is notable. Shortly before the tumult erupted, the country witnessed a dramatic decline in its unemployment rate from one of the highest in the EU ‐27 to a figure below the average. However, this turnaround was apparently driven by amendments to the country's Labour Code, which generated an enormous increase in temporary working. Using consecutive annual panels from the Labour Force Survey, a strong link between this development and the fall in unemployment is identified. A multinomial logit model reveals that the flows were most heavily concentrated among males, young workers of both sexes and the less well educated. There is also evidence that fixed‐term work lured previously discouraged individuals back into the labour market. However, the requirement that Poland aligns its temporary employment legislation with that of the EU could conceivably lead to at least a partial reversal of fortune.

"Migration of Palaearctic Passerine Birds in Wallacea." Emu - Austral Ornithology, 77(1), pp. 37–38

Abstract Many of the systems of an aircraft need to translate small command signals into large demands for power to move surfaces and mechanisms. This chapter will describe the way in which hydraulic power generation and distribution systems are designed for various types of aircraft to suit different power demands. A description will be given of typical hydraulic circuits and components and the way in which the circuits are separated to preserve the integrity of the systems using the power. The impact of technology will also be described.

Background: The necessity for rapid evaluation and treatment with intravenous tissue plasminogen activator (tPA) in acute ischemic stroke may increase the risk of administrating tPA to patients without a stroke (“stroke mimics”). Methods: Using data from the Get With The Guidelines Stroke Registry from 2009 to 2015, we identified 90,746 patients treated with tPA within 4.5 hours of symptom onset. We documented use of tPA in stroke mimics, defined as patients initially thought to have a stroke but without a final diagnosis of one, and compared patient characteristics and outcomes between tPA-treated mimics vs. ischemic strokes. Results: Overall, only 0.8% (728) of all tPA cases were given to stroke mimics, ranging from 0.2% in 2009 Q1 to 1.3% in 2015 Q1. The most common documented diagnoses in tPA-treated mimics were migraine (15.6%), functional disorder (9.4%), and seizure (7.2%). Compared with tPA-treated true stroke patients, tPA-treated mimics were younger (median 52 vs. 72 years), had lower prevalence of atrial fibrillation, coronary artery disease, dyslipidemia, hypertension, heart failure, had less severe National Institute of Health Stroke Scale (median 7 vs. 10), but higher prevalence of prior stroke/transient ischemic attack (34.4% vs. 25.5%), all p&lt;0.001. The door-to-needle times were similar in stroke mimics and true stroke groups (median 68 vs. 68 minutes, p=0.82). Rates of symptomatic intracranial hemorrhage (sICH) were quite rare in stroke mimic patients (0.4%, 3/728) as compared with 4.3% (3846/90018) in patients with an ischemic stroke; adjusted OR for sICH (0.19, 95% CI 0.06-0.58). The in-hospital mortality rate was significantly lower in tPA-treated stroke mimics as compared with ischemic stroke patients (0.6% vs. 7.3%, adjusted OR 0.16, 95% CI 0.06-0.43). Conclusions: In this large nationwide cohort of patients treated with tPA, only 1 in 125 patients who received tPA for presumed stroke was a false positive and complication rates associated with tPA administration to stroke mimics were quite low. Nonetheless, there still may be opportunities to continue to improve the rapid and accurate diagnosis and treatment of ischemic stroke.

The aircraft pneumatic systems are those that require air to perform their function. The air may be pressurized and used to perform the functions of pressurization, cooling, or actuation, or it may be used as a sensing system to provide information about the speed and altitude of the aircraft. Pressurized air can be obtained from the aircraft engines and is used to provide energy to perform a number of functions on the aircraft. Although most power transfer systems make use of hydraulic and electrical power sources of energy, there are a number of functions that still draw their supply of energy from engine bleed air. In addition, there is a system that uses atmospheric air pressure to provide a source of air data to instruments and flight control systems.

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit &gt;&gt; risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p&lt;0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p&lt;0.001) and those with NIHSS&gt;3 (18.7%, 22.8%, 28.3%, and 28.3%, p&lt;0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS&gt;3, where the risk-benefit ratio of DAPT remains to be established.

in his capacity as President of the General Board ofHealth, introduced into the House ofCommons his 'Bill to regulate the qualification of Practitioners in Medicine and Surgery'. This Bill was subsequently to become the 1858 Medical Act

Abstract With a rise in global tensions among nuclear-armed states, preventative measures against nuclear war have once again attracted attention. However, recovery measures remain heavily neglected. A nuclear winter and its associated climatic effects would devastate global agriculture. Understanding vulnerabilities in post nuclear war trade networks could inform efforts to mitigate collapse risks and enable recovery. We posit that even in a limited nuclear war, key trading chokepoints and infrastructure could be targeted, severely disrupting global trade and supply chains for food, essential medicine, fossil fuels, and fertilizers, resulting in widespread famine and increasing humanity’s vulnerability to unforeseen aftershocks. The precise mechanisms and vulnerabilities in post nuclear war trade and supply chains remain poorly understood. Large fluctuations in price compounded by infrastructure destruction will impact every part of the post catastrophe aid delivery process. The trajectory of this disruption and recovery will be critical in determining the extent of the resulting famine and loss of life. We reviewed the relevant literature for the nuclear winter hypothesis, relevant famine studies, and existing complex adaptive system research on trade and supply chains. Our modeling indicates that expected deaths would peak in 250–550 detonation scenarios, therefore, the medium exchange scenarios should be a priority for future resilience research. We identify three layers of inquiry that would help future modeling work to address nuclear resilience, and recommend their inclusion by the 2025–26 UN Independent Scientific Panel on the Effects of Nuclear War. Importantly, a better understanding of reduced sunlight scenarios is applicable to several classes of catastrophe beyond nuclear exchanges.