Clinical Management of a Patient with Chronic Recurrent Vertigo Following a Mild Traumatic Brain Injury

Vertigo, was provoked and right torsional up-beat nystagmus was observed in a 47-year-old patient when she was placed into the right Hallpike-Dix test position using infrared goggle technology. The clinical diagnosis was benign paroxysmal positional vertigo (BPPV), specifically right posterior canalithiasis, resulting from a mild traumatic brain injury (TBI) suffered approximately six-months earlier. Previous medical consultations did not include vestibular system examination, and Meclizine was prescribed to suppress her chief complaint of vertigo. Ultimately, the patient was successfully managed by performing two canalith repositioning maneuvers during a single clinical session. The patient reported 100% resolution of symptoms upon reexamination the following day, and the Hallpike-Dix test was negative. Continued symptom resolution was subjectively reported 10 days postintervention via telephone consultation. This case report supports previous publications concerning the presence of BPPV following TBI and the need for inclusion of vestibular system examination during medical consultation

Global oceanic emission of ammonia: constraints from seawater and atmospheric observations

Current global inventories of ammonia emissions identify the ocean as the largest natural source. This source depends on seawater pH, temperature, and the concentration of total seawater ammonia (NHx(sw)), which reflects a balance between remineralization of organic matter, uptake by plankton, and nitrification. Here we compare [NHx(sw)] from two global ocean biogeochemical models (BEC and COBALT) against extensive ocean observations. Simulated [NHx(sw)] are generally biased high. Improved simulation can be achieved in COBALT by increasing the plankton affinity for NHx within observed ranges. The resulting global ocean emissions is 2.5 TgN a−1, much lower than current literature values (7–23 TgN a−1), including the widely used Global Emissions InitiAtive (GEIA) inventory (8 TgN a−1). Such a weak ocean source implies that continental sources contribute more than half of atmospheric NHx over most of the ocean in the Northern Hemisphere. Ammonia emitted from oceanic sources is insufficient to neutralize sulfate aerosol acidity, consistent with observations. There is evidence over the Equatorial Pacific for a missing source of atmospheric ammonia that could be due to photolysis of marine organic nitrogen at the ocean surface or in the atmosphere. Accommodating this possible missing source yields a global ocean emission of ammonia in the range 2–5 TgN a−1, comparable in magnitude to other natural sources from open fires and soils

Primary enucleation for group D retinoblastoma in the era of systemic and targeted chemotherapy: the price of retaining an eye

BACKGROUND: Chemotherapy is increasingly used as primary treatment for group D retinoblastoma, whereas primary enucleation is considered to have a diminishing role. This study aimed to compare the management course, including number of examinations under anaesthesia (EUAs), of group D patients treated by enucleation versus chemotherapy. METHODS: A retrospective analysis of 92 group D patients, of which 40 (37 unilateral) underwent primary enucleation and 52 (17 unilateral) were treated with intravenous chemotherapy. Number of EUAs was compared between the treatment groups with respect to the whole cohort, using univariate and multivariate analysis, and to unilateral cases only. RESULTS: Patients were followed up for a median of 61 months (mean: 66, range: 14-156), in which time primary enucleated patients had on average seven EUAs and chemotherapy-treated patients 21 EUAs (p<0.001). Chemotherapy, young age, bilateral disease, multifocal tumours, familial and germline retinoblastoma were found on univariate analysis to correlate with increased number of EUAs (p≤0.019). On multivariate analysis, however, only treatment type and presentation age were found significant (p≤0.001). On subanalysis of the unilateral cases, patients undergoing primary enucleation had in average seven EUAs, as compared with 16 in the chemotherapy group (p<0.001). Of the 55 unilateral-presenting patients, a new tumour developed in the fellow eye only in a single familial case. CONCLUSION: Group D patients' families should be counselled regarding the significant difference in number of EUAs following primary enucleation versus chemotherapy when deciding on a treatment strategy. In this regard, primary enucleation would be most beneficial for older patients with unilateral disease

Primary intravenous chemotherapy for group D retinoblastoma: a 13-year retrospective analysis.

BACKGROUND: Eye salvage rate for group D retinoblastoma using intravenous chemotherapy (IVC) as a primary modality is <50%. To report on 13 years' experience with the use of primary IVC for group D retinoblastoma. METHODS: A retrospective analysis of 64 group D eyes (52 patients) treated with primary IVC, from 2002 to 2014. RESULTS: The median age at presentation was 11.0 months (mean: 18.6, range: 0.6-144.0), 35 (67%) patients had bilateral disease, 38 (73%) germline disease and 8 (15%) cases were familial. In addition to IVC, patients received a median number of three treatments (mean: 6, range: 0-24), including thermotherapy/cryotherapy, plaque radiotherapy, intra-ophthalmic artery chemotherapy (IAC) and/or intravitreous chemotherapy. External beam radiotherapy (EBRT) was used in five eyes, all of which were eventually enucleated. In a median follow-up time of 55 months (mean: 64, range: 14-156), 63% of eyes were salvaged. By the Kaplan-Meier survival analysis, globe salvage rate was 83%, 70%, 59% and 45% at 1, 3, 5 and 10 years, respectively. There were no cases of metastatic spread from intraocular retinoblastoma and no deaths. IVC-related adverse events included febrile neutropenia in 21 (40%) patients and anaphylactic reaction to carboplatin in 2 (4%), all conservatively resolved. Of the patients receiving IAC, third and sixth nerve palsies were documented in two (10%) and one (5%) eyes, respectively. CONCLUSIONS: Primary IVC for group D eyes, with adjuvant treatments as required, was found to be a safe and efficient approach, achieving 63% eye salvage rate, no metastatic spread from intraocular retinoblastoma and no deaths. IAC has now replaced EBRT as a successful salvage treatment

Structure of positive energy states in a deformed mean-field potential

We investigate the properties of single-particle resonances in a non-spherical potential by solving the coupled-channels equations for the radial wave functions. We first generalize the box discretization method for positive energy states to a deformed system. As in the spherical case, we find that the discretized energy is stabilized against the box size when a resonance condition is met. Using the wave functions thus obtained, we then discuss the energy and the radial dependences of scattering wave functions in the vicinity of an isolated resonance. In the eigenchannel basis, where the $S$-matrix is diagonal, we propose a generalized expression for the factorization formula for the multi-channel wave function. We find that the factorized wave function agrees well with the exact solution inside the centrifugal barrier when the energy distance from the resonance is less than the resonance width.Comment: 22 pages, 5 eps figures; a figure adde

Control of crystal size tailors the electrochemical performance of alpha-V2O5 as a Mg2+ intercalation host

α-V2O5 has been extensively explored as a Mg2+ intercalation host with potential as a battery cathode, offering high theoretical capacities and potentials vs. Mg2+/Mg. However, large voltage hysteresis is observed with Mg insertion and extraction, introducing significant and unacceptable round-trip energy losses with cycling. Conventional interpretations suggest that bulk ion transport of Mg2+ within the cathode particles is the major source of this hysteresis. Herein, we demonstrate that nanosizing α-V2O5 gives a measurable reduction to voltage hysteresis on the first cycle that substantially raises energy efficiency, indicating that mechanical formatting of the α-V2O5 particles contributes to hysteresis. However, no measurable improvement in hysteresis is found in the nanosized α-V2O5 in latter cycles despite the much shorter diffusion lengths, suggesting that other factors aside from Mg transport, such as Mg transfer between the electrolyte and electrode, contribute to this hysteresis. This observation is in sharp contrast to the conventional interpretation of Mg electrochemistry. Therefore, this study uncovers critical fundamental underpinning limiting factors in Mg battery electrochemistry, and constitutes a pivotal step towards a high-voltage, high-capacity electrode material suitable for Mg batteries with high energy density

The conversation: developing confidence to provide end of life care in Salford nursing homes

The study was funded by the Burdett Trust for Nursing and partly by Salford Primary Care Trust. A realistic evaluation design was used to collect data using a range of approaches, from before and after surveys of confidence in delivering end of life care, to participant observation and interviews. A total of 43 people were interviewed involving both staff, residents and relatives. Key Messages a) Significant resources are needed to engage staff, residents and relatives/carers with the idea of advance care planning b) Care home staff are optimistic about involving residents and relatives in planning care at the end of life and some relatives become very involved in care c) Clearly registered nurses and other care home workers such as care assistants have different roles, but the overlap between these and the appropriate boundaries would benefit from further work d) Talking to residents and relatives about their feelings and wishes for care at the end of life remains especially difficult, but education and training in key skills and knowledge can engender both ability and motivation e) Care homes need strong and well-informed leadership in order to implement the Gold Standards Framework f) Placing a relative in a care home involves strain and an ability to compromise ‘there’s no perfect place’ g) Advance care planning can reduce the distress and the number of inappropriate hospital admissions, but is challenging in the face of staff rotation and out of hours medical staff being unpredictable h) The principles of the Gold Standards Framework are widely seen as sensible, but clinical challenges include diagnosing and predicting dying trajectories, especially in heart failure, chronic pulmonary disease and dementia i) A particular concern of staff is how to approach nutrition and hydration as frailty and death approach j) Communicating about diagnosis and especially prognosis with residents who lack capacity is an increasing problem k) Natural justice suggests that resources should be allocated to the general standardisation of a good quality of care at the end of life in ALL care homes whatever their Care Quality Commission ratin

High power Nb-doped Lifelong₄ Li-ion battery cathodes; pilot-scale synthesis and electrochemical properties

High power, phase-pure Nb-doped LiFePO₄ (LFP) nanoparticles are synthesised using a pilot-scale continuous hydrothermal flow synthesis process (production rate of 6 kg per day) in the range 0.01–2.00 at% Nb with respect to total transition metal content. EDS analysis suggests that Nb is homogeneously distributed throughout the structure. The addition of fructose as a reagent in the hydrothermal flow process, followed by a post synthesis heat-treatment, affords a continuous graphitic carbon coating on the particle surfaces. Electrochemical testing reveals that cycling performance improves with increasing dopant concentration, up to a maximum of 1.0 at% Nb, for which point a specific capacity of 110 mAh g⁻¹ is obtained at 10 C (6 min for the charge or discharge). This is an excellent result for a high power cathode LFP based material, particularly when considering the synthesis was performed on a large pilot-scale apparatus

‘I don’t do it for myself, I do it for them’. A grounded theory study of South Asians’ experiences of making lifestyle change after myocardial infarction.

Aims and objectives: To explore South Asians’ experience of choosing and prioritising lifestyle changes during their recovery from first myocardial infarction. Background Coronary heart disease continues to be a leading cause of premature death globally. South Asians suffer increased risk of CHD and have poorer outcomes post myocardial infarction compared to other ethnic groups. Lifestyle modification alters the course of heart disease and models of behaviour change to facilitate such changes have been proposed. However, little is known about the experiences of those from the South Asian community who attempt to make these changes. Design A constructivist grounded theory design, using longitudinal, face-to-face, semi-structured in-depth interviews. Method Audio recorded interviews were conducted with a purposive sample of South Asian patients, recruited from three hospitals in the North West of England, who had suffered their first myocardial infarction at two time points (3 weeks and 16 weeks following discharge from hospital). Data collection and analysis occurred simultaneously. Transcripts were analysed line by line with focused and theoretical coding using the constant comparative method and memo writing. Settings Participants were recruited from three hospitals in the North West of England. Participants Purposive sampling was used to select South Asian patients who had recently suffered their first myocardial infarction. Results Making lifestyle changes was characterised by an inherent conflict of priorities and the need for harmony was identified as the substantive theory. The following three categories were conceptualised: patronage of the family, affinity towards one’s group and conforming to the religious and health beliefs. Patronage of the family refers to the role that family played in supporting recovery but where conflict existed between the needs of the family and the individual, family needs took priority. “Conforming to the beliefs” captures the influences of the participants’ religious and health beliefs regarding their diagnosis of heart attack and the lifestyle changes they have to make. Affinity towards one’s group referred to the conflictual nature afforded by social and religious norms. Lifestyle modifications were not given priority when conflicting with valued societal roles. To avoid conflict, decisions were based on what helped them to maintain harmony rather than individual need. Conclusion: The findings of this study show how the wider social network influences the way South Asian people choose and prioritise lifestyle changes after first myocardial infarction. South Asian patients make lifestyle changes against a backdrop of competing religious, cultural and family beliefs and need the necessary skills to resolve conflicts that emerge when attempting to make lifestyle changes. Keywords: Myocardial infarction, Cardiac rehabilitation, South Asians, Grounded theory, Shared efficac