Dealing with care disruption in High and Intensive Care wards:From difficult patients to difficult situations

High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards

Age-related curves of AMH using the Gen II, the picoAMH and the Elecsys assays in women with polycystic ovary syndrome

CONTEXT: Several challenges still exist to adopt the anti-Müllerian hormone (AMH) as a marker of polycystic ovary morphology (PCOM), as included in the recently updated international guideline. Although different evaluations of age- and assay-specific reference ranges have been published in the last years, these studies have mainly been conducted in normo-ovulatory or infertile women.OBJECTIVE: To develop an age-specific percentile distribution of AMH in patients with polycystic ovary syndrome (PCOS) measured by three different assays.DESIGN: Retrospective cross-sectional study.PATIENTS: 2,725 women aged 20 to 40 years with PCOS diagnosis were included.INTERVENTION (S): Serum AMH measurement by the Gen II (Beckman Coulter), the picoAMH (Ansh Labs), and the Elecsys (Roche) assays.MAIN OUTCOME MEAUSRE (S): Age-specific centile curves for all the assays and correlations between AMH, clinical, hormonal, and ultrasound characteristics.RESULTS: Age-related nomograms for the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles of AMH were calculated using the LMS method for all the assays. AMH levels were significantly different between PCOS phenotypes. AMH levels were positive correlated to luteinizing hormone (LH), LH/follicular stimulating hormone (FSH) ratio, testosterone, androstenedione, free androgen index, mean follicular number, and mean ovarian volume.CONCLUSIONS: To our knowledge this is the first study reporting age specific percentile nomograms of serum AMH levels measured by the Gen II, the picoAMH and the Elecsys assays in a large population of PCOS women. These findings may help to interpret AMH levels in PCOS patients and facilitate the use of AMH as a diagnostic tool across age ranges.</p

Giant deer (Megaloceros giganteus) diet from Mid-Weichselian deposits under the present North Sea inferred from molar-embedded botanical remains

The molar of a giant deer, Megaloceros giganteus (Blumenbach, 1799), was discovered in sandy deposits of the North Sea, about 10 km west of the present shoreline of the Netherlands. Compacted masticated plant remains were preserved in the molar's deep folds. A palaeoecological analysis of these plant remains shows the complete dominance of pollen from Artemisia (sage) and other Asteraceae Tubuliflorae (Compositae), indicating that the animal foraged in a steppe environment, and may have preferred to eat Artemisia, which contain a high level of nutrients such as calcium and phosphorous components, which are important for antler building. Radiocarbon dating indicates that the plant remains are of mid‐Weichselian age [38 570 (+300, −290) 14C a BP, Greenland Interstadial‐11]. This is the first study of the food choice of M. giganteus based on palaeoecological evidence. We hypothesize about links between the extirpation of M. giganteus at the onset of the Holocene in North‐West Europe and the transition from a landscape with highly dynamic geomorphological processes and consequently prevalence of immature and nutrient‐rich soils, to a less dynamic landscape with stable, leached and acidifying soils, and the decline of Artemisia and other calciphilous plants

Liquid organic hydrogen carriers:Process design and economic analysis for manufacturing N-ethylcarbazole

This paper revisits the economics of manufacturing N-ethylcarbazole (NEC), a strong candidate for large-scale liquid organic hydrogen carrier (LOHC) supply chains, because of its high H2 storage capacity (6 wt%), selective hydrogenation and dehydrogenation reactions, and favorable reaction enthalpy and reaction temperatures compared to other LOHC systems. Two different process routes for producing NEC from industrial chemicals are selected out of 10 possible options: one using aniline and the other using cyclohexanone and nitrobenzene as feedstock. The required capital and operational costs are estimated to determine a NEC break-even cost for a capacity of 225 ktpa. NEC break-even costs of $3.0 and$2.6 per kg LOHC are found for the routes. This is significantly less than the $40/kg cost that has generally been reported in literature for NEC, thus improving the economic viability of using NEC as LOHC. The total fixed capital costs are estimated to be$200 MM and $250 MM. Furthermore, the prices of the feedstock show the largest influence (76$0.77–$0.90 per kg H2 for a 60-day roundtrip and$0.09–$0.10 per kg H2 for a 7-day roundtrip. It is important to note that both routes rely heavily on laboratory scale data and the corresponding assumptions that stem from this limitation. Therefore, this research can serve as a guide to future experimental studies into validating the key assumptions made for this analysis.</p

Learning from failure

We study decentralized learning in organizations. Decentralization is captured through a symmetry constraint on agents’ strategies. Among such attainable strategies, we solve for optimal and equilibrium strategies. We model the organization as a repeated game with imperfectly observable actions. A fixed but unknown subset of action profiles are successes and all other action profiles are failures. The game is played until either there is a success or the time horizon is reached. For any time horizon, including infinity, we demonstrate existence of optimal attainable strategies and show that they are Nash equilibria. For some time horizons, we can solve explicitly for the optimal attainable strategies and show uniqueness. The solution connects the learning behavior of agents to the fundamentals that characterize the organization: Agents in the organization respond more slowly to failure as the future becomes more important, the size of the organization increases and the probability of success decreases.Game theory

Galactose inhibition of the constitutive transport of hexoses in Saccharomyces cerevisiae

The relationship between the pathways of glucose and galactose utilization in Saccharomyces cerevisiae has been studied. Galactose (which is transported and phosphorylated by inducible systems) is a strong inhibitor of the utilization of glucose, fructose and mannose (which have the same constitutive transport and phosphorylation systems). Conversely, all these three hexoses inhibit the utilization of galactose, though with poor efficiency. These cross-inhibitions only occur in yeast adapted to galactose or in galactose-constitutive mutants. The efficiency of galactose as inhibitor is even greater than the efficiencies of each of the other three hexoses to inhibit the utilization of each other. Phosphorylation is not involved in the inhibition and transport of sugars is the affected step. The cross-inhibitions between galactose and either glucose, fructose or mannose do not implicate utilization of one hexose at the expense of the other, as it occurs in the mutual interactions between the latter three sugars. it seems that, by growing the yeast in galactose, a protein component is synthesized, or alternatively modified, that once bound to either galactose or any one of the other three hexoses (glucose, fructose or mannose), cross-interacts respectively with the constitutive or the inducible transport systems, impairing their function.This work was supported by a grant (PB87-0206) from the DGICYT, Promoción General del Conocimiento.Peer Reviewe

Human C-reactive protein aggravates osteoarthritis development in mice on a high-fat diet

Objective: C-reactive protein (CRP) levels can be elevated in osteoarthritis (OA) patients. In addition to indicating systemic inflammation, it is suggested that CRP itself can play a role in OA development. Obesity and metabolic syndrome are important risk factors for OA and also induce elevated CRP levels. Here we evaluated in a human CRP (hCRP)-transgenic mouse model whether CRP itself contributes to the development of ‘metabolic’ OA.Design: Metabolic OA was induced by feeding 12-week-old hCRP-transgenic males (hCRP-tg, n = 30) and wild-type littermates (n = 15) a 45 kcal% high-fat diet (HFD) for 38 weeks. Cartilage degradation, osteophytes and synovitis were graded on Safranin O-stained histological knee joint sections. Inflammatory status was assessed by plasma lipid profiling, flow cytometric analyses of blood immune cell populations and immunohistochemical staining of synovial macrophage subsets.Results: Male hCRP-tg mice showed aggravated OA severity and increased osteophytosis compared with their wild-type littermates. Both classical and non-classical monocytes showed increased expression of CCR2 and CD86 in hCRP-tg males. HFD-induced effects were evident for nearly all lipids measured and indicated a similar low-grade systemic inflammation for both genotypes. Synovitis scores and synovial macrophage subsets were similar in the two groups.Conclusions: Human CRP expression in a background of HFD-induced metabolic dysfunction resulted in the aggravation of OA through increased cartilage degeneration and osteophytosis. Increased recruitment of classical and non-classical monocytes might be a mechanism of action through which CRP is involved in aggravating this process. These findings suggest interventions selectively directed against CRP activity could ameliorate metabolic OA development

Freestanding non-covalent thin films of the propeller-shaped polycyclic aromatic hydrocarbon decacyclene

Molecularly thin, nanoporous thin films are of paramount importance in material sciences. Their use in a wide range of applications requires control over their chemical functionalities, which is difficult to achieve using current production methods. Here, the small polycyclic aromatic hydrocarbon decacyclene is used to form molecular thin films, without requiring covalent crosslinking of any kind. The 2.5 nm thin films are mechanically stable, able to be free-standing over micrometer distances, held together solely by supramolecular interactions. Using a combination of computational chemistry and microscopic imaging techniques, thin films are studied on both a molecular and microscopic scale. Their mechanical strength is quantified using AFM nanoindentation, showing their capability of withstanding a point load of 26 ± 9 nN, when freely spanning over a 1 μm aperture, with a corresponding Young’s modulus of 6 ± 4 GPa. Our thin films constitute free-standing, non-covalent thin films based on a small PAH