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Prompt gammas imaging (PGI) is a promising method for observing a beam's shape and estimating the range of the beam from outside a subject. However 2-dimensional images of prompt gammas (PGs) during irradiation of protons were still difficult to measure. To achieve PGI, we developed a new gamma camera and imaged PGs while irradiating a phantom by proton beams. We also simultaneously measured prompt X-ray (PX) images with an X-ray camera from opposed direction and compared the images. The developed gamma camera uses a 10 mm thick GAGG block optically coupled to a flat panel photomultiplier tube (FP-PMT), and it is contained in a 20 mm thick tungsten container with a pinhole collimator attached. A poly-methyl-methacrylate (PMMA) block was irradiated by proton beams with total number of the protons similar to the clinical level, and the gamma camera imaged PGs and X-ray camera imaged PXs simultaneously. For all of the tested beams, we could measure the beam shapes of the PGs and the PXs and the ranges could also be estimated from the images. For both PG and PX images, time sequential images and accumulated images could be derived. We confirmed that the PGI using our developed gamma camera, as well as PXI, is promising for beam imaging and range estimation in proton therapy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Introduction: The knowledge regarding eating behavior and disorders in women with polycystic ovary syndrome (PCOS) and severe obesity is limited. This study aimed to assess eating behavior and lifestyle factors in women with severe obesity (BMI ≥35 kg/m 2 ), with and without PCOS, and the effect of weight loss on these behaviors., Material and Methods: A prospective clinical trial with participants screened for PCOS using National Institutes of Health criteria. Participants completed the Food Frequency Questionnaire, International Physical Activity Questionnaire, Three-Factor Eating Questionnaire, and Questionnaire of Eating and Weight Patterns-revised, and were evaluated regarding binge eating disorder using DSM-5 criteria before and after a 12-month weight loss intervention., Clinicaltrials: gov: NCT01319162., Results: 246 women were included (PCOS n = 63, age 33.0 ± 8.4, BMI 39.9 ± 4.7; non-PCOS n = 183, age 37.7 ± 8.7, BMI 39.6 ± 4.3). Women with PCOS showed elevated baseline scores in cognitive restraint eating (50.0 [33.3-63.2]) compared to women without PCOS (38.9 [27.8-55.6]; p = 0.012). No differences were observed between groups in emotional and uncontrolled eating. In both groups, cognitive restraint eating was negatively correlated with energy intake (PCOS: r = -0.315, p < 0.05; non-PCOS: r = -0.214, p < 0.001), while uncontrolled eating displayed a positive correlation with energy intake (PCOS: r = 0.263, p = 0.05; non-PCOS: r = 0.402, p < 0.001). A positive correlation was found between emotional eating and energy intake only in women without PCOS (r = 0.400, p < 0.001). Baseline self-reported energy intake and physical activity did not differ between groups. At 12-month follow-up, women with PCOS reported reduced fat intake. Women without PCOS reported reduced energy intake, carbohydrates and sugar, increased protein, reduced scores for emotional and uncontrolled eating, and heightened scores for cognitive restraint eating. Comparing changes from baseline to follow-up, differences were found between groups in cognitive restraint, intake of fat, carbohydrates, and sugar. The mean weight loss was 12-14 kg, with no between-group difference (p = 0.616)., Conclusions: Women with severe obesity and PCOS showed elevated cognitive restraint eating behaviors compared to women without PCOS. Although significant weight loss was seen in both groups, alterations in eating behavior more favorable for weight loss were only seen in women without PCOS., (© 2024 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background and objective Although early diuretic use and negative fluid balance (NFB) have been associated with lower mortality in mechanically ventilated patients, some patients are not tolerant to NFB. Little is known about whether urine output response after the diuretic administration predicts NFB tolerance in mechanically ventilated patients. Hence, we conducted this study to look into this. Methods This was a single-center, prospective, observational study. We included mechanically ventilated patients who were hemodynamically stable with bilateral pulmonary opacities on chest radiography and planned to be diuresed per our fluid removal protocol. In the protocol, a low dose of furosemide adjusted to each patient's estimated glomerular filtration rate (eGFR) was administered, and then we started to measure urine outputs hourly for four hours. Tolerance to NFB was defined as "absence of hypotension, fluid resuscitation and vasopressors use, and acute kidney injury during fluid removal". We investigated whether the urine output predicts the tolerance to NFB during fluid removal treatment. Results A total of 60 mechanically ventilated patients were included. Notably, 80% (48/60) of the patients were tolerant to NFB. All hourly and cumulative urine output measurements during the first four hours after the first diuretic administration were significantly higher in the NFB-tolerant group than in the non-tolerant group. Among all hourly and cumulative urine output measurements, the first four-hour cumulative urine output showed the highest area under the receiver operating characteristic curve (AUC) of 0.83 for predicting the tolerance to NFB. Multivariate logistic regression analysis adjusted for the urine output two hours before the diuretic use showed that each 100-mL increase in the first four-hour cumulative urine output was significantly associated with an increased odds ratio (OR) of the tolerance to NFB [adjusted odds ratio (aOR): 1.53; 95% CI: 1.11-2.15]. Conclusions Based on our findings, the first four-hour cumulative urine output after the first low dose of diuretic administration might help predict tolerance to NFB during fluid removal treatment in mechanically ventilated, critically ill patients., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board at Tokyo Bay Urayasu Ichikawa Medical Center issued approval No. 213. This study was registered with UMIN-CTR Clinical Trial (UMIN000027134) on 26/04/2017. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kataoka et al.)

This research aimed to identify materials capable of emitting visible light useful for dose management at ultra-high dose rate (uHDR). Various materials were irradiated with proton beams at a normal dose rate (NDR) and uHDR, and the resulting surface luminescence was captured using a high-sensitivity camera. The luminescence images were compared with the corresponding dose distributions. The luminescence of Tough Water Phantoms (Kyoto Kagaku Co. Ltd.) with various thicknesses was also observed to evaluate the depth distributions. Dose distributions were measured using two-dimensional ionization chamber detector arrays. The Tough Bone Phantom (Kyoto Kagaku Co. Ltd.) exhibited the strongest luminescence among the materials, followed by the Tough Water Phantom. The metals exhibited relatively weak luminescence. The luminescence profiles of the Tough Water Phantom, water, the Tough Lung Phantom (Kyoto Kagaku Co. Ltd.), and an acrylic were similar to the dose profiles. The luminescence distribution of the Tough Water Phantom in the depth direction was similar to that of the dose distributions. The luminescence at uHDR and NDR were approximately equivalent. The Tough Water Phantom was found to be a suitable material for dosimetry, even at uHDR. More detailed measurement data, such as wavelength data, must be collected to elucidate the luminescence mechanism., (© 2024. The Author(s).)

Transanal total mesorectal excision (taTME) has improved the laparoscopic dissection for rectal cancer in the narrow pelvis. Although taTME has more clinical benefits than laparoscopic surgery, such as a better view of the distal rectum and direct determination of distal resection margin, an intraoperative urethral injury could occur in excision ta-TME. This study aimed to determine the feasibility and efficacy of the ta-TME with IRIS U kit surgery. This retrospective study enrolled 10 rectal cancer patients who underwent a taTME with an IRIS U kit. The study endpoints were the safety of access (intra- or postoperative morbidity). The detectability of the IRIS U kit catheter was investigated by using a laparoscope-ICG fluorescence camera system. Their mean age was 71.4±6.4 (58-78) years; 80 were men, and 2 were women. The mean operative time was 534.6 ± 94.5 min. The coloanal anastomosis was performed in 80%, and 20% underwent abdominal peritoneal resection. Two patients encountered postoperative complications graded as Clavien-Dindo grade 2. The transanal approach with IRIS U kit assistance is feasible, safe for patients with lower rectal cancer, and may prevent intraoperative urethral injury., (© 2024. The Author(s).)

In the realm of radiation therapy, a conspicuous obstacle lies in the dearth of external observation concerning radiation beams aimed at the patient. While real-time monitoring of such beams on the patient's surface during therapy holds promise, the imaging of particle beams has thus far proven to be a formidable task. Here, we show our discovery of polyester fabrics and cloths as auspicious scintillating materials, ideally suited for the visualization of radiation beams upon the patient's surface. The light output of polyester fabrics ranged from 10 to 20% of that observed in plastic scintillators. When exposed to spot scanning proton beams, clear beam spots emerged on the surface of the polyester cloths. The movement of these scanning beams was effectively captured using a CMOS camera in a light-shield-free with lights-off environment. The resulting images provided a means for evaluating spills of the proton beams. The inherent flexibility of polyester fabrics and clothing enhances their appeal for applications in the intricate landscape of radiation therapy, promising a bright future for surface beam imaging endeavors., (© 2024. The Author(s).)

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women that is associated with an increased risk of anxiety and depression and with a lower health-related quality of life (HRQoL). PCOS is closely associated with obesity, which per se can lead to symptoms of anxiety and depression and lower HRQoL. The first-line treatment for PCOS is weight loss through lifestyle intervention, which has been shown to improve all symptoms of the syndrome. The aim of this study was to investigate symptoms of anxiety and depression and HRQoL in women with severe obesity (BMI ≥ 35) with and without PCOS, and to evaluate the effect of a one-year structured weight loss intervention. A total of 246 women with severe obesity (PCOS n = 63, non-PCOS n = 183) were included. The comprehensive psychopathological rating scale self-rating scale for affective symptoms (CPRS-S-A) and the short form-36 (SF-36) were used to assess symptoms of anxiety and depression and HRQoL. In total 72 women of the 246 women with severe obesity completed a one-year weight loss programme and were followed up and compared with baseline data. In women with severe obesity, there were no differences in symptoms of anxiety and depression and HRQoL between women with and without PCOS at baseline. Clinically relevant anxiety symptoms were present in 71.3% (PCOS) and 65.6% (non-PCOS), and depression symptoms were present in 56.4% (PCOS) and 52.2% (non-PCOS). Significant weight loss improved physical HRQoL in all women, but reduced symptoms of anxiety and depression only in women without PCOS. There were no differences when comparing the changes between the groups. Women with severe obesity are severely affected by symptoms of anxiety and depression, independent of PCOS. Weight loss improved symptoms of anxiety and depression in women without PCOS, but there were no differences between groups in change from baseline to follow-up.Trial registration number: Clinical trial.gov: NCT01319162, March 18, 2011. Date of registration and enrolment of the first subject September 2011., (© 2024. The Author(s).)

Osmotic demyelination syndrome (ODS) occurs in patients with diabetes and hyponatremia. We herein report a case of ODS with chorea detected on serial magnetic resonance imaging (MRI), despite no prompt hyponatremia correction. A 74-year-old man with cirrhosis and uncontrolled type 2 diabetes developed an altered mental status and chorea during treatment for diabetic ketoacidosis (DKA). Despite no rapid sodium correction and normal initial brain MRI findings, serial MRI revealed ODS-related abnormalities. Clinicians should consider ODS in patients with DKA and a hyperosmolar hyperglycemic state displaying unconsciousness and neurological manifestations, including chorea, even without substantial changes in serum sodium levels. An MRI re-examination can help capture missing ODS complications.

We elucidate the decomposition mechanism of hydrogen peroxide, which is formed by water radiolysis, by gold nanoparticles (GNPs) under X-ray irradiation. The variations in yields of hydrogen peroxide generated in the presence of GNPs are evaluated using the Ghormley technique. The increase of yields of OH radicals has been quantified using Ampliflu® Red solutions. Almost all hydrogen peroxide generated by irradiation of <25 Gy is decomposed by GNPs, while the yield of OH radicals increases by 1.6 times. The amount of OH radicals thus obtained is almost equivalent to that of the decomposed hydrogen peroxide. The decomposition of hydrogen peroxide is an essential reaction to produce additional OH radicals efficiently in the vicinity of GNPs., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Objective . Prompt gamma photon, prompt x-ray, and induced positron imaging are possible methods for observing a proton beam's shape from outside the subject. However, since these three types of images have not been measured simultaneously nor compared using the same subject, their advantages and disadvantages remain unknown for imaging beam shapes in therapy. To clarify these points, we developed a triple-imaging-modality system to simultaneously measure prompt gamma photons, prompt x-rays, and induced positrons during proton beam irradiation to a phantom. Approach . The developed triple-imaging-modality system consists of a gamma camera, an x-ray camera, and a dual-head positron emission tomography (PET) system. During 80 MeV proton beam irradiation to a polymethyl methacrylate (PMMA) phantom, imaging of prompt gamma photons was conducted by the developed gamma camera from one side of the phantom. Imaging of prompt x-rays was conducted by the developed x-ray camera from the other side. Induced positrons were measured by the developed dual-head PET system set on the upper and lower sides of the phantom. Main results . With the proposed triple-imaging-modality system, we could simultaneously image the prompt gamma photons and prompt x-rays during proton beam irradiation. Induced positron distributions could be measured after the irradiation by the PET system and the gamma camera. Among these imaging modalities, image quality was the best for the induced positrons measured by PET. The estimated ranges were actually similar to those imaged with prompt gamma photons, prompt x-rays and induced positrons measured by PET. Significance . The developed triple-imaging-modality system made possible to simultaneously measure the three different beam images. The system will contribute to increasing the data available for imaging in therapy and will contribute to better estimating the shapes or ranges of proton beam., (© 2024 Institute of Physics and Engineering in Medicine.)

High-resolution and real-time imaging of particle ion trajectories is essential in nuclear medicine and nuclear engineering. One potential method to achieve high-resolution real-time trajectory imaging of particle ions involves utilizing an imaging system that integrates a scintillator plate with a magnifying unit and a cooled electron multiplying charge-coupled device (EM-CCD) camera. However, acquiring an EM-CCD camera might prove challenging due to the discontinuation of CCD sensor manufacturing by vendors. As an alternative imaging approach, a low-noise, high-sensitivity camera utilizing a cooled complementary metal-oxide-semiconductor (CMOS) sensor offers a promising solution for imaging particle ion trajectories. Yet, it remains uncertain whether CMOS-based cameras can perform as effectively as CCD-based cameras in capturing particle ion trajectories. To address these concerns, we conducted a comparative analysis of the imaging performance between a CMOS-based system and an EM-CCD-based system for capturing alpha particle trajectories. The results revealed that both systems could image the trajectories of alpha particle, but the spatial resolution with the CMOS-based camera exceeded that of the EM-CCD-based camera, primarily due to the smaller pixel size of the sensor. While the signal-to-noise ratio (SNR) of the trajectory image from the CMOS-based camera initially lagged behind that from the EM-CCD-based camera, this disparity was mitigated by implementing binning techniques on the CMOS-based camera images. In conclusion, our findings suggest that a cooled CMOS camera could serve as a viable alternative for imaging particle ion trajectories., Competing Interests: Declaration of competing interest The authors declare no conflict of interest associated with this manuscript titled “A comparative study of EM-CCD and CMOS cameras for particle ion trajectory imaging”., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

High sensitivity and high resolution is desired in such technologies as neutron radiography. However, the contamination of gamma photons in neutron images decreases the accuracy of neutron radiography. To solve this problem, we developed an event-by-event based neutron imaging system that can selectively detect neutrons. The developed neutron imaging system consists of an Li-ZnS(Ag) scintillator plate optically coupled to a flat panel photomultiplier tube (FP-PMT) with a light guide. Scintillation light emitted from the Li-ZnS(Ag) by the interaction with neutron-induced particles is used to calculate the position based on the center of mass calculations. The spatial resolution of the neutron imaging detector is ∼2.3 mm FWHM, and the sensitivity for 252 Cf at 2 cm from the source with 2-cm-thick polystyrene is 20 cps/MBq. Background count fraction from 60 Co gamma photons was 0.2 %. For various types of neutron absorption phantoms, high-contrast and high-resolution neutron images are obtained with the developed neutron imaging detector using a 252 Cf neutron source., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Objectives: This study aimed to examine the association between ABCDEF bundles and long-term postintensive care syndrome (PICS)-related outcomes., Design: Secondary analysis of the J-PICS study., Setting: This study was simultaneously conducted in 14 centers and 16 ICUs in Japan between April 1, 2019, and September 30, 2019., Patients: Adult ICU patients who were expected to be on a ventilator for at least 48 hours., Interventions: None., Measurements and Main Results: Bundle compliance for the last 24 hours was recorded using a checklist at 8:00 am The bundle compliance rate was defined as the 3-day average of the number of bundles performed each day divided by the total number of bundles. The relationship between the bundle compliance rate and PICS prevalence (defined by the 36-item Short Form Physical Component Scale, Mental Component Scale, and Short Memory Questionnaire) was examined. A total of 191 patients were included in this study. Of these, 33 patients (17.3%) died in-hospital and 48 (25.1%) died within 6 months. Of the 96 patients with 6-month outcome data, 61 patients (63.5%) had PICS and 35 (36.5%) were non-PICS. The total bundle compliance rate was 69.8%; the rate was significantly lower in the 6-month mortality group (66.6% vs 71.6%, p = 0.031). Bundle compliance rates in patients with and without PICS were 71.3% and 69.9%, respectively ( p = 0.61). After adjusting for confounding variables, bundle compliance rates were not significantly different in the context of PICS prevalence ( p = 0.56). A strong negative correlation between the bundle compliance rate and PICS prevalence ( r = -0.84, R 2 = 0.71, p = 0.035) was observed in high-volume centers., Conclusions: The bundle compliance rate was not associated with PICS prevalence. However, 6-month mortality was lower with a higher bundle compliance rate. A trend toward a lower PICS prevalence was associated with higher bundle compliance in high-volume centers., Competing Interests: Dr. Koga disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objective . Precise monitoring of the position and dwell time of iridium-192 (Ir-192) during high-dose-rate (HDR) brachytherapy is crucial to avoid serious damage to normal tissues. Source imaging using a compact gamma camera is a potential approach for monitoring. However, images from the gamma camera are affected by blurring and statistical noise, which impact the accuracy of source position monitoring. This study aimed to develop a deep-learning approach for estimating ideal source images that reduce the effect of blurring and statistical noise from experimental images captured using a compact gamma camera. Approach . A double pix2pix model was trained using the simulated gamma camera images of an Ir-192 source. The first model was responsible for denoising the Ir-192 images, whereas the second model performed super resolution. Trained models were then applied to the experimental images to estimate the ideal images. Main results . At a distance of 100 mm between the compact gamma camera and the Ir-192 source, the difference in full width at half maximum (FWHM) between the estimated and actual source sizes was approximately 0.5 mm for a measurement time of 1.5 s. This difference has been improved from approximately 2.7 mm without the use of DL. Even with a measurement time of 0.1 s, the ideal images could be estimated as accurately as in the 1.5 s measurements. This method consistently achieved accurate estimations of the source images at any position within the field of view; however, the difference increased with the distance between the Ir-192 source and the compact gamma camera. Significance . The proposed method successfully provided estimated images from the experimental images within errors smaller than 0.5 mm at 100 mm. This method is promising for reducing blurring and statistical noise from the experimental images, enabling precise real-time monitoring of Ir-192 sources during HDR brachytherapy., (© 2023 IOP Publishing Ltd.)

Detailed measurements of the spectral structure of cosmic-ray electrons and positrons from 10.6 GeV to 7.5 TeV are presented from over 7 years of observations with the CALorimetric Electron Telescope (CALET) on the International Space Station. The instrument, consisting of a charge detector, an imaging calorimeter, and a total absorption calorimeter with a total depth of 30 radiation lengths at normal incidence and a fine shower imaging capability, is optimized to measure the all-electron spectrum well into the TeV region. Because of the excellent energy resolution (a few percent above 10 GeV) and the outstanding e/p separation (10^{5}), CALET provides optimal performance for a detailed search of structures in the energy spectrum. The analysis uses data up to the end of 2022, and the statistics of observed electron candidates has increased more than 3 times since the last publication in 2018. By adopting an updated boosted decision tree analysis, a sufficient proton rejection power up to 7.5 TeV is achieved, with a residual proton contamination less than 10%. The observed energy spectrum becomes gradually harder in the lower energy region from around 30 GeV, consistently with AMS-02, but from 300 to 600 GeV it is considerably softer than the spectra measured by DAMPE and Fermi-LAT. At high energies, the spectrum presents a sharp break around 1 TeV, with a spectral index change from -3.15 to -3.91, and a broken power law fitting the data in the energy range from 30 GeV to 4.8 TeV better than a single power law with 6.9 sigma significance, which is compatible with the DAMPE results. The break is consistent with the expected effects of radiation loss during the propagation from distant sources (except the highest energy bin). We have fitted the spectrum with a model consistent with the positron flux measured by AMS-02 below 1 TeV and interpreted the electron+positron spectrum with possible contributions from pulsars and nearby sources. Above 4.8 TeV, a possible contribution from known nearby supernova remnants, including Vela, is addressed by an event-by-event analysis providing a higher proton-rejection power than a purely statistical analysis.

Objective. FLASH radiation therapy with ultrahigh dose rates (UHDR) has the potential to reduce damage to normal tissue while maintaining anti-tumor efficacy. However, rapid and precise dose distribution measurements remain difficult for FLASH radiation therapy with proton beams. To solve this problem, we performed luminescence imaging of water following irradiation by a UHDR proton beam captured using a charge-coupled device camera. Approach . We used 60 MeV proton beams with dose rates of 0.03-837 Gy s -1 from a cyclotron. Therapeutic 139.3 MeV proton beams with dose rates of 0.45-4320 Gy s -1 delivered by a synchrotron-based proton therapy system were also tested. The luminescent light intensity induced by the UHDR beams was compared with that produced by conventional beams to compare the dose rate dependency of the light intensity and its profile. Main results . Luminescence images of water were clearly visualized under UHDR conditions, with significantly shorter exposure times than those with conventional beams. The light intensity was linearly proportional to the delivered dose, which is similar to that of conventional beams. No significant dose-rate dependency was observed for 0.03-837 Gy s -1 . The light-intensity profiles of the UHDR beams agreed with those of conventional beams. The results did not differ between accelerators (synchrotron or cyclotron) and beam energies. Significance . Luminescence imaging of water is achievable with UHDR proton beams as well as with conventional beams. The proposed method should be suitable for rapid and easy quality assurance investigations for proton FLASH therapy, because it facilitates real-time, filmless measurements of dose distributions, and is useful for rapid feedback., (© 2023 Institute of Physics and Engineering in Medicine.)

Recently, in-beam positron emission tomography (PET) has been actively researched for reducing biological washout effects and dose monitoring during irradiation. However, the positron distribution does not precisely reflect the dose distribution since positron production and ionization are completely different physical processes. Thus, a novel in-beam system was proposed to determine proton dose range by measuring scattered protons with dozens of scintillation detectors surrounding the body surface. While previous studies conducted a preliminary experiment with a simple phantom, we simulated more complex situations in this paper. Especially, we conducted three stepwise simulation studies to demonstrate the feasibility of the proposed method. First, a simple rectangular phantom was reproduced on simulation and irradiated with protons for obtaining current values and Monte Carlo (MC) dose. Next, we trained a deep learning model to estimate 2-dimensional-dose range (2D-DL dose) from measured current values for simulation (A). We simulated plastic scintillators as detectors to measure the scattered protons. Second, a rectangular phantom with an air layer was used, and 3D-DL dose was estimated in simulation (B). Finally, a cylindrical phantom that mimics the human body was used for confirming the estimation quality of the simulation (C). Consequently, the position of the Bragg peak was estimated with an error of 1.0 mm in simulation (A). In addition, the position of the air layer, as well as the verifying peak position with an error of 2.1 mm, was successfully estimated in simulation (B). Although the estimation error of the peak position was 12.6 mm in simulation (C), the quality was successfully further improved to 9.3 mm by incorporating the mass density distribution obtained from the computed tomography (CT). These simulation results demonstrated the potential of the as-proposed verification system. Additionally, the effectiveness of CT utilization for estimating the DL dose was also indicated., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sato, Yokokawa, Hosobuchi and Kataoka.)

Prompt x-ray imaging is a promising method for observing the beam shape from outside a subject. However, its distribution is different from dose distribution, and thus a comparison with the dose is required. Meanwhile, luminescence imaging of water is a possible method for imaging the dose distribution. Consequently, we performed simultaneous imaging of luminescence and prompt x-rays during irradiation by proton beams to compare the distributions between these two different imaging methods. Optical imaging of water was conducted with spot-scanning proton beams at clinical dose level during irradiation to a fluorescein (FS) water phantom set in a black box. Prompt x-ray imaging was also conducted simultaneously from outside the black box using a developed x-ray camera during proton beam irradiation to the phantom. We measured images of the luminescence of FS water and prompt x-rays for various types of proton beams, including pencil beams, spread-out Bragg peak (SOBP) beams, and clinically used therapy beams. After the imaging, ranges were estimated from FS water and prompt x-rays and compared with those calculated with a treatment planning system (TPS). We could measure the prompt x-ray and FS water images simultaneously for all types of proton beams. The ranges estimated from the FS water and those calculated with the TPS closely matched, within a difference of several mm. Similar range difference was found between the results estimated from prompt x-ray images and those calculated with the TPS. We confirmed that the simultaneous imaging of luminescence and prompt x-rays were possible during irradiation with spot-scanning proton beams at a clinical dose level. This method can be applied to range estimation as well as comparison with the dose for prompt x-ray imaging or other imaging methods used in therapy with various types of proton beams at a clinical dose level., (© 2023 IOP Publishing Ltd.)

Objective . Prompt x-ray imaging using a low-energy x-ray camera is a promising method for observing a proton beam's shape from outside the subject. Furthermore, imaging of positrons produced by nuclear reactions with protons is a possible method for observing the beam shape. However, it has not been possible to measure these two types of images with a single imaging system due to the limited imaging capability of existing systems. Imaging of both prompt x-rays and the distribution of positrons may compensate for the shortcomings of each method. Approach . We conducted imaging of the prompt x-ray using a pinhole x-ray camera during irradiation with protons in list mode. Then, after irradiation with protons, imaging of annihilation radiations from the produced positrons was conducted using the same pinhole x-ray camera in list mode. After this imaging, list-mode data were sorted to obtain prompt x-ray images and positron images. Main results . With the proposed procedure, we could measure both prompt x-ray images and induced positron images with a single irradiation by a proton beam. From the prompt x-ray images, ranges and widths of the proton beams could be estimated. The distributions of positrons were slightly wider than those of the prompt x-rays. From the time sequential positron images, we could derive the time activity curves of the produced positrons. Significance . Hybrid imaging of prompt x-rays and induced positrons using a pinhole x-ray camera was achieved. The proposed procedure would be useful for measuring prompt x-ray images during irradiation to estimate the beam structures as well as for measuring the induced positron images after irradiation to estimate the distributions and time activity curves of the induced positrons., (© 2023 Institute of Physics and Engineering in Medicine.)

We present the observation of a charge-sign dependent solar modulation of galactic cosmic rays (GCRs) with the Calorimetric Electron Telescope onboard the International Space Station over 6 yr, corresponding to the positive polarity of the solar magnetic field. The observed variation of proton count rate is consistent with the neutron monitor count rate, validating our methods for determining the proton count rate. It is observed by the Calorimetric Electron Telescope that both GCR electron and proton count rates at the same average rigidity vary in anticorrelation with the tilt angle of the heliospheric current sheet, while the amplitude of the variation is significantly larger in the electron count rate than in the proton count rate. We show that this observed charge-sign dependence is reproduced by a numerical "drift model" of the GCR transport in the heliosphere. This is a clear signature of the drift effect on the long-term solar modulation observed with a single detector.

Prompt secondary electron bremsstrahlung X-ray (prompt X-ray) imaging using a low-energy X-ray camera is a promising method for observing a beam shape from outside the subject. However, such imaging has so far been conducted only for pencil beams without a multi-leaf collimator (MLC). The use of spread-out Bragg peak (SOBP) with an MLC may increase the scattered prompt gamma photons and decrease the contrast of the images of prompt X-rays. Consequently, we performed prompt X-ray imaging of SOBP beams formed with an MLC. This imaging was carried out in list mode during irradiation of SOBP beams to a water phantom. An X-ray camera with a 1.5-mm diameter as well as 4-mm-diameter pinhole collimators was used for the imaging. List mode data were sorted to obtain the SOBP beam images as well as energy spectra and time count rate curves. Due to the high background counts from the scattered prompt gamma photons penetrating the tungsten shield of the X-ray camera, the SOBP beam shapes were difficult to observe with a 1.5-mm-diameter pinhole collimator. With the 4-mm-diameter pinhole collimators, images of SOBP beam shapes at clinical dose levels could be obtained with the X-ray camera. The use of a 4-mm-diameter pinhole collimator attached to the X-ray camera is effective for prompt X-ray imaging with high sensitivity and low background counts. This approach makes it possible to image SOBP beams with an MLC when the counts are low and the background levels are high., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

We present the results of a direct measurement of the cosmic-ray helium spectrum with the CALET instrument in operation on the International Space Station since 2015. The observation period covered by this analysis spans from October 13, 2015, to April 30, 2022 (2392 days). The very wide dynamic range of CALET allowed for the collection of helium data over a large energy interval, from ∼40  GeV to ∼250  TeV, for the first time with a single instrument in low Earth orbit. The measured spectrum shows evidence of a deviation of the flux from a single power law by more than 8σ with a progressive spectral hardening from a few hundred GeV to a few tens of TeV. This result is consistent with the data reported by space instruments including PAMELA, AMS-02, and DAMPE and balloon instruments including CREAM. At higher energy we report the onset of a softening of the helium spectrum around 30 TeV (total kinetic energy). Though affected by large uncertainties in the highest energy bins, the observation of a flux reduction turns out to be consistent with the most recent results of DAMPE. A double broken power law is found to fit simultaneously both spectral features: the hardening (at lower energy) and the softening (at higher energy). A measurement of the proton to helium flux ratio in the energy range from 60  GeV/n to about 60  TeV/n is also presented, using the CALET proton flux recently updated with higher statistics.

High-resolution imaging of alpha particles is required in the detection of alpha radionuclides in cells or small organs for the development of radio-compounds for targeted alpha-particle therapy or other purposes. We developed an ultrahigh resolution, real time alpha-particle imaging system for observing the trajectories of alpha particles in a scintillator. The developed system is based on a magnifying unit and a cooled electron multiplying charge-coupled device (EM-CCD) camera, combined with a 100-µm-thick Ce-doped Gd 3 Al 2 Ga 3 O 12 (GAGG) scintillator plate. Alpha particles from an Am-241 source were irradiated to the GAGG scintillator and imaged with the system. Using our system, we measured the trajectories of the alpha particles having different shapes in real time. In some of these measured trajectories, the line shapes of the alpha particles that flew in the GAGG scintillator were clearly observed. The lateral profiles of the alpha-particle trajectories were imaged with widths of ~ 2 µm. We conclude that the developed imaging system is promising for research on targeted alpha-particle therapy or other alpha particle detections that require high spatial resolution., (© 2023. The Author(s).)

Rationale: The prevalence of burnout among critical care professionals during the coronavirus disease (COVID-19) pandemic varies in different countries. Objectives: To investigate the prevalence of burnout and turnover intention in Japanese critical care professionals in March 2021. Methods: This cross-sectional study used a web-based survey of Japanese critical care professionals working in 15 intensive care units in 15 prefectures. Burnout was measured using the Mini Z 2.0 Survey. Intention to leave (turnover intention) was assessed by survey. Resilience was measured using the Brief Resilience Scale (Japanese version). Demographics and personal and workplace characteristics were also collected. Results: Of 1,205 critical care professionals approached, 936 (77.6%) completed the survey. Among these, 24.3%, 20.6%, and 14.2% reported symptoms of burnout, depression, and anxiety, respectively. A total of 157 respondents (16.8%) reported turnover intention. On multivariate analysis, higher resilience scores (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.84-0.95; and OR, 0.94; 95% CI, 0.91-0.96) and perceived support from the hospital (OR, 0.64; 95% CI, 0.44-0.93; and OR, 0.54; 95% CI, 0.40-0.73) were associated with a lower odds of burnout and turnover intention, respectively. Conclusions: Approximately 24% and 17% of the Japanese critical care professionals surveyed had symptoms of burnout and turnover intention from critical care, respectively, during the COVID-19 pandemic. Such professionals require organizational support to cultivate both individual and organizational resilience to reduce burnout and turnover intention.

We present the measurement of the energy dependence of the boron flux in cosmic rays and its ratio to the carbon flux in an energy interval from 8.4  GeV/n to 3.8  TeV/n based on the data collected by the Calorimetric Electron Telescope (CALET) during ∼6.4  yr of operation on the International Space Station. An update of the energy spectrum of carbon is also presented with an increase in statistics over our previous measurement. The observed boron flux shows a spectral hardening at the same transition energy E&#95;{0}∼200  GeV/n of the C spectrum, though B and C fluxes have different energy dependences. The spectral index of the B spectrum is found to be γ=-3.047±0.024 in the interval 25

Purpose: Measurement of the dwell time and moving speed of a high-activity iridium-192 (Ir-192) source used for high-dose-rate (HDR) brachytherapy is important for estimating the precise dose delivery to a tumor. For this purpose, we used a cerium-doped yttrium aluminum perovskite (YA1O 3 :YAP(Ce)) gamma camera system, combined with a list-mode data acquisition system that can acquire short-time sequential images, and measured the dwell times and moving speeds of the Ir-192 source., Methods: Gamma photon imaging was conducted using the gamma camera in list mode for the Ir-192 source of HDR brachytherapy with fixed dwell times and positions. The acquired list-mode images were sorted to millisecond-order interval time sequential images to evaluate the dwell time at each position. Time count rate curves were derived to calculate the dwell time at each source position and moving speed of the source., Results: We could measure the millisecond-order time sequential images for the Ir-192 source. The measured times for the preset dwell times of 2 s and 10 s were 1.98 to 2.00 s full width at half maximum (FWHM) and 10.0 s FWHM, respectively. The dwell times at the first dwell position were larger than those at other positions. We also measured the moving speeds of the source after the dwells while moving back to the afterloader and found the speed increased with the distance from the edge of the field of view to the last dwell position., Conclusion: We conclude that millisecond-order time sequential imaging of the Ir-192 source is possible by using a gamma camera and is useful for evaluating the dwell times and moving speeds of the Ir-192 source., (© 2022 American Association of Physicists in Medicine.)

Purpose: Although real-time imaging of the high-activity iridium-192 (Ir-192) source position during high-dose-rate (HDR) brachytherapy using a high-energy gamma camera system is a promising approach, the energy window was not optimized for spatial resolution or scatter fraction., Methods: By using a list-mode data-acquisition system that can acquire energy information of a cerium-doped yttrium aluminum perovskite (YA1O 3 : YAP(Ce)) gamma camera, we tried to optimize the energy window's setting to improve the spatial resolution and reduce scatter fraction., Results: The spatial resolution was highest for the central energy of the window at ∼300 keV. The scatter fraction was also smallest for the central energy of the window at ∼300 keV, and the scatter fraction was more than 48 % smaller than that for the full energy window., Conclusions: We clarified that the spatial resolution can be improved and the scatter fraction can be reduced through optimizing the energy window of the YAP(Ce) gamma camera by setting the central energy of the window to ∼300 keV for HDR brachytherapy., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Women with polycystic ovary syndrome (PCOS) have high circulating anti-Müllerian hormone (AMH) levels which is correlated with antral follicle count and polycystic ovarian morphology and negatively correlated with body mass index (BMI). Moreover, diet-induced weight loss in women with PCOS and overweight or obesity, reduce or normalize AMH-levels. There is, however, no previous study investigating the circulating AMH levels in women with severe obesity and how a structured diet-induced weight loss program affects circulating AMH levels in these women. Therefore, this study aims to investigate circulating AMH levels in a population of women with severe obesity (BMI ≥ 35 kg/m 2 ) with and without PCOS, as diagnosed by the NIH-criteria, and to investigate the effect of a one-year weight loss program with a very low-energy diet (VLED) on circulating levels of AMH., Methods: In a prospective cohort-study, were 246 women with severe obesity were screened for PCOS diagnosis with the NIH-criteria, circulating AMH and anthropometry were measured at baseline and after a 12-month weight loss intervention with very low-energy diet (VLED)., Results: Mean BMI was 39.9 ± 4.7 (PCOS), 39.6 ± 4.3 (non-PCOS) P = 0.960. Circulating AMH was higher in women with PCOS (5.47 ± 4.89 µg/L) compared with non-PCOS (2.66 ± 3.71 µg/L) P < 0.001 and was positively correlated with circulating total testosterone in both groups. Next, we performed ROC-analyses, and show that circulating AMH could not discriminate women with PCOS and severe obesity from non-PCOS women with severe obesity. Finally, a one-year weight reduction program does not affect circulating AMH levels despite significant weight loss neither in women with PCOS, nor without PCOS and severe obesity., Conclusion: Women with severe obesity and PCOS have elevated levels of circulating AMH compared to women without the syndrome. AMH-levels could not discriminate women with PCOS from non-PCOS because of low sensitivity and specificity. Significant weight loss was not associated with changes in circulating AMH levels, neither in women with, nor without PCOS and severe obesity. These results imply that in women with severe obesity, a greater weight loss may be needed to improve reproductive features, independent of PCOS diagnosis., Trial Registration Number: Clinical trial.gov: NCT01319162., (© 2022. The Author(s).)

A precise measurement of the cosmic-ray proton spectrum with the Calorimetric Electron Telescope (CALET) is presented in the energy interval from 50 GeV to 60 TeV, and the observation of a softening of the spectrum above 10 TeV is reported. The analysis is based on the data collected during ∼6.2  years of smooth operations aboard the International Space Station and covers a broader energy range with respect to the previous proton flux measurement by CALET, with an increase of the available statistics by a factor of ∼2.2. Above a few hundred GeV we confirm our previous observation of a progressive spectral hardening with a higher significance (more than 20 sigma). In the multi-TeV region we observe a second spectral feature with a softening around 10 TeV and a spectral index change from -2.6 to -2.9 consistently, within the errors, with the shape of the spectrum reported by DAMPE. We apply a simultaneous fit of the proton differential spectrum which well reproduces the gradual change of the spectral index encompassing the lower energy power-law regime and the two spectral features observed at higher energies.

Objective: Dose distribution measurements of high-energy X-rays from medical linear accelerators (LINAC) in water are important for quality control (QC) of the system. Although Cherenkov-light imaging is a useful method for measuring the high-energy X-ray dose distribution, depth profiles have an underestimated dose at increased depths due to the angular dependency of the Cherenkov light generated in water. In this study, we use a linear polarizer to separate the majority of polarized components from the majority of unpolarized components of Cherenkov-light images in water and then use this information to correct for angular dependencies., Methods: A water phantom, a cooled charge-coupled device (CCD) camera, and a polarizer were installed in a black box. Then, the water phantom was irradiated from the upper side with 6 or 10 MV X-rays, and the Cherenkov light generated in water was imaged with the polarizer axis at both parallel and perpendicular orientations to the beam. By using these images from the two orientations relative to the beam, we corrected the angular dependency of the Cherenkov light., Results: By subtracting the images measured with the polarizer perpendicular to the beams from the images measured with the polarizer parallel to the beams, we could obtain images with only the polarized components. Using these images, we could calculate the images with non-polarized components that had similar depth profiles to those calculated with a planning system. The average difference between corrected depth profiles and those calculated with the planning system was less than 1%, while that between uncorrected depth profiles and the planning system was more than 8.3% in depths of water from 20 to 100 mm., Conclusion: We conclude that the use of the polarizer has the potential to improve the accuracy of dose distribution in Cherenkov-light imaging of water using high-energy X-rays., (© 2022 American Association of Physicists in Medicine.)

Background: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021., Methods: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method., Results: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO 2 (PaO 2 ) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D)., Conclusions: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs&#95;guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries., Competing Interests: Conflict of Interest All committee members and panelists submitted disclosure forms of financial and academic conflict of interest (COI) prior to being requested to participate in individual activities. If panelists have any COI concerning each CQ, other panelists were assigned to replace the vacancy. All COI were collected according to the guideline written by Japanese Society of Intensive Care Medicine. Detailed information of COI and the roles in creating this clinical guideline are summarized in Additional file 7., (Copyright © 2022 [The Author/The Authors]. Published by Elsevier B.V. All rights reserved.)

The relative abundance of cosmic ray nickel nuclei with respect to iron is by far larger than for all other transiron elements; therefore it provides a favorable opportunity for a low background measurement of its spectrum. Since nickel, as well as iron, is one of the most stable nuclei, the nickel energy spectrum and its relative abundance with respect to iron provide important information to estimate the abundances at the cosmic ray source and to model the Galactic propagation of heavy nuclei. However, only a few direct measurements of cosmic-ray nickel at energy larger than ∼3  GeV/n are available at present in the literature, and they are affected by strong limitations in both energy reach and statistics. In this Letter, we present a measurement of the differential energy spectrum of nickel in the energy range from 8.8  to 240  GeV/n, carried out with unprecedented precision by the Calorimetric Electron Telescope (CALET) in operation on the International Space Station since 2015. The CALET instrument can identify individual nuclear species via a measurement of their electric charge with a dynamic range extending far beyond iron (up to atomic number Z=40). The particle's energy is measured by a homogeneous calorimeter (1.2 proton interaction lengths, 27 radiation lengths) preceded by a thin imaging section (3 radiation lengths) providing tracking and energy sampling. This Letter follows our previous measurement of the iron spectrum [1O. Adriani et al. (CALET Collaboration), Phys. Rev. Lett. 126, 241101 (2021).PRLTAO0031-900710.1103/PhysRevLett.126.241101], and it extends our investigation on the energy dependence of the spectral index of heavy elements. It reports the analysis of nickel data collected from November 2015 to May 2021 and a detailed assessment of the systematic uncertainties. In the region from 20 to 240  GeV/n our present data are compatible within the errors with a single power law with spectral index -2.51±0.07.

For radiological diagnosis and radionuclide therapy, X-ray and gamma-ray imaging technologies are essential. Single-photon emission tomography (SPECT) and positron emission tomography (PET) play essential roles in radiological diagnosis, such as the early detection of tumors. Radionuclide therapy is also rapidly developing with the use of these modalities. Nevertheless, a limited number of radioactive tracers are imaged owing to the limitations of the imaging devices. In a previous study, we developed a hybrid Compton camera that conducts simultaneous Compton and pinhole imaging within a single system. In this study, we developed a system that simultaneously realizes three modalities: Compton, pinhole, and PET imaging in 3D space using multiple hybrid Compton cameras. We achieved the simultaneous imaging of Cs-137 (Compton mode targeting 662 keV), Na-22 (PET mode targeting 511 keV), and Am-241 (pinhole mode targeting 60 keV) within the same field of view. In addition, the imaging of Ga-67 and In-111, which are used in various diagnostic scenarios, was conducted. We also verified that the 3D distribution of the At-211 tracer inside a mouse could be imaged using the pinhole mode., (© 2022. The Author(s).)

Purpose: Of the various methods used, the laparoscopic surgical repair of inguinal hernias is widely performed. We aimed to estimate the incidence of bilateral and contralateral occult inguinal hernias in our surgical population and to compare the results of total extraperitoneal repair (TEP) for bilateral and unilateral inguinal hernias, occult and non-occult hernias., Methods: We retrospectively reviewed data of patients who underwent TEP for the repair of adult inguinal hernias from January 2012 to November 2018 in our hospital., Results: Of the data of 259 patients included, 134 (51.7%) and 125 (48.3%) had unilateral and bilateral inguinal hernias, respectively, while 70 patients (27%) were found to have a contralateral occult inguinal hernia, intraoperatively. The mean operative time was 129 ± 48 minutes (range, 43-300 minutes) and 167 ± 55 minutes (range, 85-390 minutes) for the unilateral and bilateral groups, respectively, indicating a significantly longer duration of surgery for the bilateral group (P < .05). Recurrence occurred in 1.5% (5/134) and 0.4% (1/250) of the operated hernias in the unilateral and the bilateral groups, respectively, indicating a significantly lower rate of recurrence in the latter group (P < .05). The two groups showed no statistically significant differences with respect to the remaining perioperative data. The incidence of postoperative complications in occult hernias was not significantly different from that in non-occult hernias., Conclusions: Our TEP method, involving a laparoscopic exploration from the intraperitoneal side, can be safely and effectively utilized for the repair of both bilateral and contralateral occult inguinal hernias., (© 2021 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Background: A cough peak flow (CPF) of < 60 L/min was associated with increased risk of extubation failure after a successful spontaneous breathing trial (SBT). Passive cephalic excursion of the diaphragm (PCED), measured by ultrasonography during cough expiration, was reported to predict CPF in healthy adults. We hypothesized that PCED, diaphragm peak velocity, or both during cough, as measured by ultrasonography, might predict CPF and extubation outcomes in mechanically ventilated patients. This study attempted to identify associations of diaphragm movement during cough, as assessed by ultrasonography with simultaneously measured CPF, and to determine predictive values of ultrasonographic indices for extubation outcomes after a successful SBT., Methods: In the study, 252 mechanically ventilated subjects with a successful SBT were enrolled in a prospective cohort study. Right hemidiaphragm passive cephalic excursion and peak velocity were measured by ultrasonography during voluntary cough expiration with maximum effort. CPF was measured simultaneously by ultrasonography., Results: A multiple regression model adjusted for age and sex showed a significant association between PCED and CPF ( P < .001, adjusted β coefficient 11.4, 95% CI 8.88-14.0, adjusted R 2 = 0.287) and between diaphragm peak velocity and CPF ( P < .001, adjusted β coefficient 1.71, 95% CI 1.91-2.24, adjusted R 2 = 0.235). The areas under the curves of PCED, diaphragm peak velocity, and CPF for extubation failure were 0.791 (95% Cl 0.668-0.914), 0.587 (95% Cl 0.426-0.748), and 0.765 (95% Cl 0.609-0.922), respectively., Conclusions: PCED on ultrasonography was significantly associated with CPF and extubation failure after a successful SBT. Future studies should investigate if this method is applicable for determination of tracheostomy decannulation in stable patients in general wards., Competing Interests: The authors have no conflicts to disclose., (Copyright © 2021 by Daedalus Enterprises.)

The Calorimetric Electron Telescope (CALET), in operation on the International Space Station since 2015, collected a large sample of cosmic-ray iron over a wide energy interval. In this Letter a measurement of the iron spectrum is presented in the range of kinetic energy per nucleon from 10  GeV/n to 2.0  TeV/n allowing the inclusion of iron in the list of elements studied with unprecedented precision by space-borne instruments. The measurement is based on observations carried out from January 2016 to May 2020. The CALET instrument can identify individual nuclear species via a measurement of their electric charge with a dynamic range extending far beyond iron (up to atomic number Z=40). The energy is measured by a homogeneous calorimeter with a total equivalent thickness of 1.2 proton interaction lengths preceded by a thin (3 radiation lengths) imaging section providing tracking and energy sampling. The analysis of the data and the detailed assessment of systematic uncertainties are described and results are compared with the findings of previous experiments. The observed differential spectrum is consistent within the errors with previous experiments. In the region from 50  GeV/n to 2  TeV/n our present data are compatible with a single power law with spectral index -2.60±0.03.

Background: Validation and standardization of methodologies for microbial community measurements by high-throughput sequencing are needed to support human microbiome research and its industrialization. This study set out to establish standards-based solutions to improve the accuracy and reproducibility of metagenomics-based microbiome profiling of human fecal samples., Results: In the first phase, we performed a head-to-head comparison of a wide range of protocols for DNA extraction and sequencing library construction using defined mock communities, to identify performant protocols and pinpoint sources of inaccuracy in quantification. In the second phase, we validated performant protocols with respect to their variability of measurement results within a single laboratory (that is, intermediate precision) as well as interlaboratory transferability and reproducibility through an industry-based collaborative study. We further ascertained the performance of our recommended protocols in the context of a community-wide interlaboratory study (that is, the MOSAIC Standards Challenge). Finally, we defined performance metrics to provide best practice guidance for improving measurement consistency across methods and laboratories., Conclusions: The validated protocols and methodological guidance for DNA extraction and library construction provided in this study expand current best practices for metagenomic analyses of human fecal microbiota. Uptake of our protocols and guidelines will improve the accuracy and comparability of metagenomics-based studies of the human microbiome, thereby facilitating development and commercialization of human microbiome-based products. Video Abstract.

Background: Many studies have compared quality of life of post-intensive care syndrome (PICS) patients with age-matched population-based controls. Many studies on PICS used the 36-item Short Form (SF-36) health survey questionnaire version 2, but lack the data for SF-36 values before and after intensive care unit (ICU) admission. Thus, clinically important changes in the parameters of SF-36 are unknown. Therefore, we determined the frequency of co-occurrence of PICS impairments at 6 months after ICU admission. We also evaluated the changes in SF-36 subscales and interpreted the patients' subjective significance of impairment., Methods: A prospective, multicenter, observational cohort study was conducted in 16 ICUs across 14 hospitals in Japan. Adult ICU patients expected to receive mechanical ventilation for > 48 h were enrolled, and their 6-month outcome was assessed using the questionnaires. PICS definition was based on the physical status, indicated by the change in SF-36 physical component score (PCS) ≥ 10 points; mental status, indicated by the change in SF-36 mental component score (MCS) ≥ 10 points; and cognitive function, indicated by the worsening of Short-Memory Questionnaire (SMQ) score and SMQ score at 6 months < 40. Multivariate logistic regression model was used to identify the factors associated with PICS occurrence. The patients' subjective significance of physical and mental symptoms was assessed using the 7-scale Global Assessment Rating to evaluate minimal clinically important difference (MCID)., Results: Among 192 patients, 48 (25%) died at 6 months. Among the survivors at 6 months, 96 patients responded to the questionnaire; ≥ 1 PICS impairment occurred in 61 (63.5%) patients, and ≥ 2 occurred in 17 (17.8%) patients. Physical, mental, and cognitive impairments occurred in 32.3%, 14.6% and 37.5% patients, respectively. Population with only mandatory education was associated with PICS occurrence (odds ratio: 4.0, 95% CI 1.1-18.8, P = 0.029). The MCID of PCS and MCS scores was 6.5 and 8.0, respectively., Conclusions: Among the survivors who received mechanical ventilation, 64% had PICS at 6 months; co-occurrence of PICS impairments occurred in 20%. PICS was associated with population with only mandatory education. Future studies elucidating the MCID of SF-36 scores among ICU patients and standardizing the PICS definition are required. Trial registration UMIN000034072.

In this paper, we present the measurement of the energy spectra of carbon and oxygen in cosmic rays based on observations with the Calorimetric Electron Telescope on the International Space Station from October 2015 to October 2019. Analysis, including the detailed assessment of systematic uncertainties, and results are reported. The energy spectra are measured in kinetic energy per nucleon from 10  GeV/n to 2.2  TeV/n with an all-calorimetric instrument with a total thickness corresponding to 1.3 nuclear interaction length. The observed carbon and oxygen fluxes show a spectral index change of ∼0.15 around 200  GeV/n established with a significance >3σ. They have the same energy dependence with a constant C/O flux ratio 0.911±0.006 above 25  GeV/n. The spectral hardening is consistent with that measured by AMS-02, but the absolute normalization of the flux is about 27% lower, though in agreement with observations from previous experiments including the PAMELA spectrometer and the calorimetric balloon-borne experiment CREAM.