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Background: Minimal invasive liver resections are a safe alternative to open surgery. Different scoring systems considering different risks factors have been developed to predict the risks associated with these procedures, especially challenging major liver resections (MLR). However, the impact of neoadjuvant chemotherapy (NAT) on the difficulty of minimally invasive MLRs remains poorly investigated. Methods: Patients who underwent laparoscopic and robotic MLRs for colorectal liver metastases (CRLM) performed across 57 centers between January 2005 to December 2021 were included in this analysis. Patients who did or did not receive NAT were matched based on 1:1 coarsened exact and 1:2 propensity-score matching. Pre- and post-matching comparisons were performed. Results: In total, the data of 5189 patients were reviewed. Of these, 1411 procedures were performed for CRLM, and 1061 cases met the inclusion criteria. After excluding 27 cases with missing data on NAT, 1034 patients (NAT: n = 641; non-NAT: n = 393) were included. Before matching, baseline characteristics were vastly different. Before matching, the morbidity rate was significantly higher in the NAT-group (33.2% vs. 27.2%, p-value = 0.043). No significant differences were seen in perioperative outcomes after the coarsened exact matching. After the propensity-score matching, statistically significant higher blood loss (mean, 300 (SD 128–596) vs. 250 (SD 100–400) ml, p-value = 0.047) but shorter hospital stay (mean, 6 [4-8] vs. 6 [5-9] days, p-value = 0.043) were found in the NAT-group. Conclusion: The current study demonstrated that NAT had minimal impact on the difficulty and outcomes of minimally-invasive MLR for CRLM.

Objective: To establish global benchmark outcomes indicators after laparoscopic liver resections (L-LR). Background: There is limited published data to date on the best achievable outcomes after L-LR. Methods: This is a post hoc analysis of a multicenter database of 11,983 patients undergoing L-LR in 45 international centers in 4 continents between 2015 and 2020. Three specific procedures: left lateral sectionectomy (LLS), left hepatectomy (LH), and right hepatectomy (RH) were selected to represent the 3 difficulty levels of L-LR. Fifteen outcome indicators were selected to establish benchmark cutoffs. Results: There were 3519 L-LR (LLS, LH, RH) of which 1258 L-LR (40.6%) cases performed in 34 benchmark expert centers qualified as low-risk benchmark cases. These included 659 LLS (52.4%), 306 LH (24.3%), and 293 RH (23.3%). The benchmark outcomes established for operation time, open conversion rate, blood loss ≥500 mL, blood transfusion rate, postoperative morbidity, major morbidity, and 90-day mortality after LLS, LH, and RH were 209.5, 302, and 426 minutes; 2.1%, 13.4%, and 13.0%; 3.2%, 20%, and 47.1%; 0%, 7.1%, and 10.5%; 11.1%, 20%, and 50%; 0%, 7.1%, and 20%; and 0%, 0%, and 0%, respectively. Conclusions: This study established the first global benchmark outcomes for L-LR in a large-scale international patient cohort. It provides an up-to-date reference regarding the "best achievable" results for L-LR for which centers adopting L-LR can use as a comparison to enable an objective assessment of performance gaps and learning curves.

Background: Presently, according to different difficulty scoring systems, there is no difference in complexity estimation of laparoscopic liver resection (LLR) of segments 7 and 8. However, there is no published data supporting this assumption. To date, no studies have compared the outcomes of laparoscopic parenchyma-sparing resection of the liver segments 7 and 8. Methods: A post hoc analysis of patients undergoing LLR of segments 7 and 8 in 46 centers between 2004 and 2020 was performed. 1:1 Propensity score matching (PSM) was used to compare isolated LLR of segments 7 and 8. Subset analyses were also performed to compare atypical resections and segmentectomies of 7 and 8. Results: A total of 2411 patients were identified, and 1691 patients met the inclusion criteria. Comparison after PSM between the entire cohort of segment 7 and segment 8 resections revealed inferior results for segment 7 resection in terms of increased blood loss, blood transfusions, and conversions to open surgery. Subset analyses of only atypical resections similarly demonstrated poorer outcomes for segment 7 in terms of increased blood loss, operation time, blood transfusions, and conversions to open surgery. Conversely, a subgroup analysis of segmentectomies after PSM found better outcomes for segment 7 in terms of a shorter operation time and hospital stay. Conclusion: Differences in the outcomes of segments 7 and 8 resections suggest a greater difficulty of laparoscopic atypical resection of segment 7 compared to segment 8, and greater difficulty of segmentectomy 8 compared to segmentectomy 7.

Background: Aggression in psychiatric hospitals has been of interest to researchers. Information on how different stakeholders perceive patient aggression remains equivocal. Even less is known about possible similarities or differences in stakeholders’ perceptions of how aggressive behaviour is understood, managed and prevented in psychiatric hospitals. We aimed to explore multiple viewpoints on patient aggression, its possible causes and outcomes, and development ideas for prevention and management. Methods: A qualitative design was adopted. The data were collected using focus group interviews. A thematic approach was used for interpretation. The data were collected on 15 adult wards in two inpatient psychiatric settings in Hong Kong. Participants were nurses working on the psychiatric inpatient wards, patients admitted to the wards, and informal caregivers visiting inpatient wards (N = 94). Results: Commonalities between all groups were found on how patient aggression is perceived, and why it occurs. Patients and especially nurses described how patient aggression occurred with no clear reason or forewarning and how patients were physically controlled or restricted after aggressive events. Only nurses and patients expressed experiencing physical burden, while all groups considered psychological burden to be a consequence of aggression. All groups proposed that helpful attitudes among nurses, better communication, structural changes, and better self-management skills would prevent patient aggression. Risk assessment was proposed only by nurses and patients, while safety measures were proposed by nurses and informal caregivers only. The use of restrictive interventions to manage aggressive events was proposed by all groups. Conclusions: Despite the complex diversity of perspectives in different stakeholder groups regarding patient aggression, the findings highlighted that it is possible to achieve some mutual understanding of aggression in psychiatric hospitals and i

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

BACKGROUND: Symptoms of depression and pain often overlap, and they negatively influence the prognosis and treatment outcome of both conditions. However, the comorbidity of depression and pain has not been examined using network analysis, especially in the context of a pandemic. Thus, we mapped out the network connectivity among the symptoms of depression and pain in Wuhan residents in China during the late stage of the COVID-19 pandemic. METHODS: This cross-sectional study was conducted from May 25, 2020 to June 18, 2020 in Wuhan, China. Participants' depressive and pain symptoms were assessed using the 9-item Patient Health Questionnaire (PHQ9) and a pain numeric rating scale (NRS), respectively. Network analyses were performed. RESULTS: In total, 2,598 participants completed all assessments. PHQ4 (fatigue) in the depression community showed the highest strength value, followed by PHQ6 (worthlessness) and PHQ2 (depressed or sad mood). PHQ4 (fatigue) was also the most key bridge symptom liking depression and pain, followed by PHQ3 (sleep difficulties). There were no significant differences in network global strength (females: 4.36 vs. males: 4.29; S = 0.075, P = 0.427), network structure-distribution of edge weights (M = 0.12, P = 0.541), and individual edge weights between male and female participants. CONCLUSION: Depressive and pain symptoms showed strong cross-association with each other. "Fatigue" was the strongest central and bridge symptom in the network model, while "sleep difficulties" was the second strongest bridge symptom. Targeting treatment of both fatigue and sleep problems may help improve depressive and pain symptoms in those affected.

BACKGROUND: Hypomanic symptoms between bipolar-I disorder (BD-I) and bipolar-II disorder (BD-II) are often indistinguishable in clinical practice. This study compared the network structure of hypomanic symptoms between patients with BD-I and BD-II. METHODS: The 32-item Hypomania Checklist (HCL-32) was used to assess hypomanic symptoms. Network model was generated in BD-I and BD-II patients. Centrality index of strength was used to quantify the importance of each symptom in the network. The Network Comparison Test (NCT) was used to assess the differences in hypomanic symptoms between BD-I and BD-II patients. RESULTS: Altogether, 423 patients with BD (BD-I: 191 and BD-II: 232) were included. The most central symptom was HCL17 "I am more flirtatious and/or am more sexually active" (strength BD-I = 5.21) and HCL12 "I have more ideas, I am more creative" (strength BD-II = 6.84) in BD-I and BD-II samples, respectively. The results of NCT showed that four nodes (HCL12 "I have more ideas, I am more creative," HCL17 "I am more flirtatious and/or am more sexually active," HCL23 "My thoughts jump from topic to topic," and HCL31 "I drink more alcohol") were significantly different between the BD-I and BD-II samples. Two edges (HCL3 "I am more self-confident"-HCL17 "I am more flirtatious and/or am more sexually active," and HCL10 "I am physically more active (sport, etc.)"-HCL24 "I do things more quickly and/or more easily") were significantly stronger in BD-I compared to BD-II patients. CONCLUSION: The network structure of hypomanic symptoms is different between BD-I and BD-II patients. Interventions targeting the respective central symptoms and edges should be developed for BD-I and BD-II separately.

BACKGROUND: Schizophrenia (SCZ) is a severe psychiatric disorder that involves inflammatory processes. The aim of this study was to explore the field of inflammation-related research in SCZ from a bibliometric perspective. METHODS: Regular and review articles on SCZ- and inflammation-related research were obtained from the Web of Science Core Collection (WOSCC) database from its inception to February 19, 2022. R package "bibliometrix" was used to summarize the main findings, count the occurrences of the top keywords, visualize the collaboration network between countries, and generate a three-field plot. VOSviewer software was applied to conduct both co-authorship and co-occurrence analyses. CiteSpace was used to identify the top references and keywords with the strongest citation burst. RESULTS: A total of 3,596 publications on SCZ and inflammation were included. Publications were mainly from the USA, China, and Germany. The highest number of publications was found in a list of relevant journals. Apart from "schizophrenia" and "inflammatory", the terms "bipolar disorder," "brain," and "meta-analysis" were also the most frequently used keywords. CONCLUSIONS: This bibliometric study mapped out a fundamental knowledge structure consisting of countries, institutions, authors, journals, and articles in the research field of SCZ and inflammation over the past 30 years. The results provide a comprehensive perspective about the wider landscape of this research area.

BACKGROUND: A high proportion of clinicians experienced common anxiety, insomnia and depression during the COVID-19 pandemic. This study examined the item-level association of comorbid anxiety and insomnia symptoms among clinicians who suffered from depressive symptoms during the late stage of the COVID-19 pandemic using network analysis (NA). METHODS: Clinicians with depressive symptoms (with a Patients Health Questionnaire (PHQ-9) total score of 5 and above) were included in this study. Anxiety and insomnia symptoms were measured using the Generalized Anxiety Disorder Scale - 7-item (GAD-7) and Insomnia Severity Index (ISI), respectively. Network analysis was conducted to investigate the network structure, central symptoms, bridge symptoms, and network stability of these disturbances. Expected influence (EI) was used to measure the centrality of index. RESULTS: Altogether, 1729 clinicians were included in this study. The mean age was 37.1 [standard deviation (SD)=8.04 years], while the mean PHQ-9 total score was 8.42 (SD=3.33), mean GAD-7 total score was 6.45 (SD=3.13) and mean ISI total score was 8.23 (SD=5.26). Of these clinicians, the prevalence of comorbid anxiety symptoms (GAD-7≥5) was 76.8% (95% CI 74.82-78.80%), while the prevalence of comorbid insomnia symptoms (ISI≥8) was 43.8% (95% CI: 41.50-46.18%). NA revealed that nodes ISI7 ("Interference with daytime functioning") (EI=1.18), ISI4 ("Sleep dissatisfaction") (EI=1.08) and ISI5 ("Noticeability of sleep problem by others") (EI=1.07) were the most central (influential) symptoms in the network model of comorbid anxiety and insomnia symptoms in clinicians. Bridge symptoms included nodes PHQ3 ("Sleep") (bridge EI=0.55) and PHQ4 ("Fatigue") (bridge EI=0.49). Gender did not significantly influence the network structure, but "having the experience of caring for COVID-19 patients" significantly influenced the network structure. CONCLUSION: Central symptoms and key bridge symptoms identified in this NA should be

Background: The 2019 novel coronavirus disease (COVID-19) outbreak had a detrimental impact on the mental health of older adults. This study evaluated the central symptoms and their associations in the network of depressive symptoms and compared the network structure differences between male and female older adults in Hong Kong. Methods: Altogether, 3,946 older adults participated in this study. We evaluated the centrality indicators for network robustness using stability and accuracy tests, and examined the potential differences between the structure and connectivity of depression networks in male and female older adults. Results: The overall prevalence of depressive symptoms was 43.7% (95% CI=40.6-46.7%) in males, and 54.8% (95% CI=53.1-56.5%) in females (P<0.05). Sad Mood, Guilt, Motor problems and Lack of Energy were influential symptoms in the network model. Gender differences were found in the network global strength, especially in the following edges: Sad Mood--Guilt, Concentration--Guilt, Anhedonia--Motor, Lack of Energy--Suicide, Appetite--Suicide and Concentration--Suicide. Conclusions: Central symptoms in the depressive symptom network among male and female older adults may be prioritized in the treatment and prevention of depression during the pandemic.

BACKGROUND: The Brain-Gut Axis, a bidirectional signaling pathway that connects the intestinal and central nervous systems, plays an important role in the development of psychiatric disorders. However, the overall research trends in this field are unclear. This study explored the patterns of research on the brain-gut axis and psychiatric disorders from a bibliometric perspective. METHODS: Relevant data were retrieved from the Web of Science Core Collection, with search terms on psychiatric disorders and the brain-gut axis. R (version 4.2.0), VOSviewer (version 1.6.17), CiteSpace software, and the online bibliometric platform were used in the data analysis. RESULTS: A total of 2,298 articles published between 1993 and 2022 were identified, showing an increasing trend over time. China (1,859; 20.70%) was the country that contributed the most publications. The journal Nutrients (95; 4.13%) published the most publications. Cryan JF (153; H-index=73) and University College Cork (559; 22.54%) were the most influential author and the most productive institution, respectively. The high-frequency keywords were clustered into six themes, including neurodegenerative diseases, stress-related diseases, immune, brain behavior, depression, and probiotic-related topics; of which, depression (880; 2019), anxiety (207; 2018) and autism (191; 2019) were the most studied psychiatric disorders in the past 5 years. "Depressive symptom" (2019-2020) and "probiotic treatment" (2019-2020) were the main areas addressed in recent years. CONCLUSION: Research on the brain-gut axis and psychiatric disorders has attracted increasing attention in the past decade, with most publications originating from high-income level countries. This study provides a useful perspective on understanding the research trends, key hot topics, and research gaps in this expanding field.

Introduction: The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated. Methods: Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes. Results: The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle’s maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality. Conclusion: Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes.

Background: Tumor size (TS) represents a critical parameter in the risk assessment of laparoscopic liver resections (LLR). Moreover, TS has been rarely related to the extent of liver resection. The aim of this study was to study the relationship between tumor size and difficulty of laparoscopic left lateral sectionectomy (L-LLS). Methods: The impact of TS cutoffs was investigated by stratifying tumor size at each 10 mm-interval. The optimal cutoffs were chosen taking into consideration the number of endpoints which show a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. Results: A total of 1910 L-LLS were included. Overall, open conversion and intraoperative blood transfusion were 3.1 and 3.3%, respectively. The major morbidity rate was 2.7% and 90-days mortality 0.6%. Three optimal TS cutoffs were identified: 40-, 70-, and 100-mm. All the selected cutoffs showed a significant discriminative power for the prediction of open conversion, operative time, blood transfusion and need of Pringle maneuver. Moreover, 70- and 100-mm cutoffs were both discriminative for estimated blood loss and major complications. A stepwise increase in rates of open conversion rate (Z = 3.90, P <.001), operative time (Z = 3.84, P <.001), blood loss (Z = 6.50, P <.001), intraoperative blood transfusion rate (Z = 5.15, P <.001), Pringle maneuver use (Z = 6.48, P <.001), major morbidity(Z = 2.17, P =.030) and 30-days readmission (Z = 1.99, P =.047) was registered as the size increased. Conclusion: L-LLS for tumors of increasing size was associated with poorer intraoperative and early postoperative outcomes suggesting increasing difficulty of the procedure. We determined three optimal TS cutoffs (40-, 70- and 100-mm) to accurately stratify surgical difficulty after L-LLS.

Attitudes toward aggression is a controversial phenomenon in psychiatry. This study examined and compared attitudes toward patient aggression in psychiatric hospitals from the perspectives of nurses, patients and informal caregivers and identified factors associated to these attitudes. A total of 2,424 participants completed a self-reported instrument regarding attitudes toward aggression (12-items Perception of Aggression Scale; POAS-S). We analysed data from nurses (n = 782), patients (n = 886), and informal caregivers (n = 765). Pearson’s r correlations were used to examine associations between variables. Differences between group scores were analysed using ANOVA/MANOVA with post-hoc Sheffe tests. Multivariate logistic regression models and logistic regression analysis were used to examine the effects of respondents’ characteristics on their attitudes toward aggression. Nurses had significantly more negative and less tolerant perceptions toward aggression (mean [SD] 47.1 [7.5], p<0.001) than the patients (mean [SD] 44.4 [8.2]) and the informal caregivers (mean [SD] 45.0 [6.9), according to the POAS-S total scores. The same trend was found with the dysfunction and function sub-scores (mean [SD] 25.3 [4.1] and 15.0 [3.6], respectively); the differences between the groups were statistically significant (p <0.001) when nurses’ scores were compared to those of both the patients (mean [SD] 23.7 [5.3] and 14.0 [4.1], respectively) and the informal caregivers (mean [SD] 24.4 [4.2] and 13.9 [3.5], respectively). The study offers new understanding of aggressive behavior in different treatment settings where attitudes toward patient behavior raises ethical and practical dilemmas. These results indicate a need for more targeted on-the-job training for nursing staff, aggression management rehabilitation programs for patients, and peer-support programs for informal caregivers focused on patient aggression.

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

Background: Aggression in psychiatric hospitals has been of interest to researchers. Information on how different stakeholders perceive patient aggression remains equivocal. Even less is known about possible similarities or differences in stakeholders’ perceptions of how aggressive behaviour is understood, managed and prevented in psychiatric hospitals. We aimed to explore multiple viewpoints on patient aggression, its possible causes and outcomes, and development ideas for prevention and management. Methods: A qualitative design was adopted. The data were collected using focus group interviews. A thematic approach was used for interpretation. The data were collected on 15 adult wards in two inpatient psychiatric settings in Hong Kong. Participants were nurses working on the psychiatric inpatient wards, patients admitted to the wards, and informal caregivers visiting inpatient wards (N = 94). Results: Commonalities between all groups were found on how patient aggression is perceived, and why it occurs. Patients and especially nurses described how patient aggression occurred with no clear reason or forewarning and how patients were physically controlled or restricted after aggressive events. Only nurses and patients expressed experiencing physical burden, while all groups considered psychological burden to be a consequence of aggression. All groups proposed that helpful attitudes among nurses, better communication, structural changes, and better self-management skills would prevent patient aggression. Risk assessment was proposed only by nurses and patients, while safety measures were proposed by nurses and informal caregivers only. The use of restrictive interventions to manage aggressive events was proposed by all groups. Conclusions: Despite the complex diversity of perspectives in different stakeholder groups regarding patient aggression, the findings highlighted that it is possible to achieve some mutual understanding of aggression in psychiatric hospitals and i

Background: CPAP is widely accepted as the gold standard treatment for severe OSA, however low socioeconomic status is associated with poor uptake and adherence to therapy. CPAP treatment is not universally subsidised under any Australian Government scheme, limiting access to CPAP for low income earners with severe OSA. The Monash CPAP Program is run through a public hospital clinic and offers significantly subsidised CPAP treatment to Pensioner Concession Card holders with at least moderate OSA and who meet clinical and adherence criteria. We studied a group of patients enrolled into the program to determine their baseline characteristics, the time on the waitlist for a CPAP machine, as well as their adherence at follow up. Method(s): We identified patients who met the eligibility criteria and placed on the waitlist between 1st January 2015 to 31st December 2015. Baseline demographic information, polysomnography data and time on the waitlist were determined from a database. We reviewed the medical records for follow up and any missing data. If no follow up was recorded, the patient was contacted and asked a short questionnaire regarding their adherence to therapy. Progress to date: 194 patients were waitlisted over the 12 month study period. Mean total AHI was 52.4/hr at the time of waitlisting. Mean time spent on the waitlist was 193 days. Preliminary analysis based on 25 patients shows an adherence rate of 70% after at least 6 months. Intended outcome and impact: Our primary aim is to identify the level of adherence to CPAP in the study population. We hypothesise adequate adherence will be present in > 50% of subjects, based on previously published data. Secondary aims will examine the effects of time on the waitlist, baseline OSA severity and symptoms on adherence. This analysis will be useful in assessing the impact of funded CPAP and provide a guide as to whether patients most in need are receiving access to treatment in a timely fashion., T. Cheung, Monash Health, Australia, CONFERENCE ABSTRACT

We report the prevalence of reduced levels of carbon monoxide transfer factor (TLCO) in middle-aged current or ex-smokers with normal spirometry. Spirometry and TLCO measurements were performed and we identified 391 subjects aged 40-60 years, with a significant smoking history and normal spirometry. In this group, 96 subjects (24%) had TLCO measuremements below the lower limit of normal when using the newly established Global Lung Initiative (GLI) reference equations. The measurement of TLCO should be considered as part of the standard assessment of smokers.Copyright © 2021

Background: Upper airway surgery (UAS) is an accepted treatment alternative to continuous positive airway pressure therapy (CPAP) for patients with Obstructive Sleep Apnoea (OSA). Current clinical tools cannot accurately predict who will respond to UAS for OSA. Whilst Computed Tomography has been used extensively to evaluate the effects of UAS on the upper airway, Magnetic Resonance Imaging (MRI) is emerging as a useful imaging modality with the advantages of superior resolution of soft tissue boundaries and the avoidance of radiation exposure. Segmentation, the process of software-assisted image analysis to identify anatomical boundaries to allow accurate calculation of cross-sectional areas and volumes, has been used in conjunction with MRI to understand how alternatives to CPAP therapy such as oral appliances improve the upper-airway and whether this information can be used to predict response to therapy. However, to our knowledge, MRI-based segmentation has not been used to study patients undergoing UAS. Our aim is to use these advanced imaging analysis techniques to quantify changes in the dimensions of upper airway structures before and after surgery and to identify the changes that predict a favourable surgical outcome. Method(s): In an ongoing prospective study, 17 patients with OSA deemed suitable for UAS underwent a volumetric T1-weighted MRI scan of the upper airway at baseline and again three months after UAS. Single-night polysomnography was performed before and after in each case to assess for presence and severity of OSA. Using an open source software platform for medical image processing and analysis, the upper airway was segmented slice-by-slice in the axial plane by one author blinded to the operative status of the patient (i.e. pre-UAS vs. post-UAS). Analysis of the data was performed by an unblinded author not involved in the airway segmentation. Progress to date: Preliminary analysis of the total airway volume of 15 patients showed that the airw

We report the prevalence of reduced levels of carbon monoxide transfer factor (TLCO) in middle-aged current or ex-smokers with normal spirometry. Spirometry and TLCO measurements were performed and we identified 391 subjects aged 40-60 years, with a significant smoking history and normal spirometry. In this group, 96 subjects (24%) had TLCO measuremements below the lower limit of normal when using the newly established Global Lung Initiative (GLI) reference equations. The measurement of TLCO should be considered as part of the standard assessment of smokers.Copyright © 2021

Background: Upper airway surgery (UAS) is an accepted treatment alternative to continuous positive airway pressure therapy (CPAP) for patients with Obstructive Sleep Apnoea (OSA). Current clinical tools cannot accurately predict who will respond to UAS for OSA. Whilst Computed Tomography has been used extensively to evaluate the effects of UAS on the upper airway, Magnetic Resonance Imaging (MRI) is emerging as a useful imaging modality with the advantages of superior resolution of soft tissue boundaries and the avoidance of radiation exposure. Segmentation, the process of software-assisted image analysis to identify anatomical boundaries to allow accurate calculation of cross-sectional areas and volumes, has been used in conjunction with MRI to understand how alternatives to CPAP therapy such as oral appliances improve the upper-airway and whether this information can be used to predict response to therapy. However, to our knowledge, MRI-based segmentation has not been used to study patients undergoing UAS. Our aim is to use these advanced imaging analysis techniques to quantify changes in the dimensions of upper airway structures before and after surgery and to identify the changes that predict a favourable surgical outcome. Method(s): In an ongoing prospective study, 17 patients with OSA deemed suitable for UAS underwent a volumetric T1-weighted MRI scan of the upper airway at baseline and again three months after UAS. Single-night polysomnography was performed before and after in each case to assess for presence and severity of OSA. Using an open source software platform for medical image processing and analysis, the upper airway was segmented slice-by-slice in the axial plane by one author blinded to the operative status of the patient (i.e. pre-UAS vs. post-UAS). Analysis of the data was performed by an unblinded author not involved in the airway segmentation. Progress to date: Preliminary analysis of the total airway volume of 15 patients showed that the airw

Close contacts of those with COVID-19 (CC) may experience distress and long-lasting mental health effects. However, the mental health status and quality of life (QOL) in CC have not been adequately examined. This study examined the mental health status and QOL in CC during the post-COVID-19 period. This cross-sectional study comprised 1169 CC and 1290 who were non-close contacts (non-CC). Demographic data were collected; depression, fatigue, post-traumatic stress symptoms (PTSS) and QOL were assessed using the Patient Health Questionnaire - 9 items (PHQ-9), fatigue numeric rating scale, Post-Traumatic Stress Disorder Checklist - 17 items (PCL-17), and the World Health Organization Quality of Life Questionnaire - brief version (WHOQOL-BREF), respectively. Analysis of covariance was used to compare depressive symptoms, QOL, fatigue, and PTSS between the CC and non-CC groups. Multiple logistic regression analyses were performed to determine the independent correlates for depression, fatigue, PTSS, and QOL in the CC group. Compared to the non-CC group, the CC group reported significantly more severe depression (F(1, 2458) = 5.58, p = 0.018) and fatigue (F(1, 2458) = 9.22, p = 0.002) in the post-COVID-19 period. No significant differences in PTSS and QOL between the CC and non-CC groups were found (F(1, 2458) = 2.93, p = 0.087 for PTSS; F(1, 2458) = 3.45, p = 0.064 for QOL). In the CC group, younger age, financial loss due to COVID-19, and perception of poor or fair health status were significantly associated with depression and fatigue, while frequent use of mass media was significantly associated with fatigue. In conclusion, close contacts of COVID-19 patients experienced high levels of depression and fatigue in the post-COVID-19 period. Due to the negative effects of depression and fatigue on daily functioning, early detection and timely interventions should be provided to this neglected population.

Background: As COVID-19 vaccination programs are being implemented widely, it is important to examine the attitudes of adolescents toward the COVID-19 vaccine and its uptake. The aim of this study was to examine the acceptance of and attitudes toward COVID-19 vaccines, and their associated factors among adolescents in China. Methods: This was a cross-sectional, observational study conducted between November 27, 2020 and March 12, 2021 using snowball sampling method. Basic sociodemographic characteristics, health-related information, severity of depressive and anxiety symptoms, and attitudes and behavior toward COVID-19 vaccines were assessed. Results: Overall, 1,057 adolescents participated in this study, yielding a response rate of 89.3%. There were 799 (75.59%) [95% Confidence Interval (CI) 73.00-78.18%] adolescents who would accept future COVID-19 vaccination. Binary logistic regression analysis revealed that adolescents who previously heard about COVID-19 vaccines (P = 0.001, odds ratio (OR) = 1.90, 95%CI:1.32-2.74), who thought that COVID-19 vaccines could protect them from COVID-19 infection (P = 0.002, OR = 2.93, 95%CI: 1.49-5.70), and those who encouraged their family members and friends to get vaccinated (P < 0.001, OR = 12.19, 95%CI: 6.78-21.92) and who believed that vaccines are safe (P = 0.012, OR = 3.94, 95%CI: 1.36-11.44) were more likely to accept future COVID-19 vaccination. In addition, younger adolescents (P = 0.003, OR = 0.93, 95%CI: 0.89-0.98) were more likely to accept future COVID-19 vaccines than older adolescents. Conclusions: In conclusion, Chinese adolescents appeared to have positive attitudes toward COVID-19 vaccines. It is important to increase public confidence and knowledge regarding the efficacy and safety of COVID-19 vaccines to maximize the success of vaccination programs.

The impact of the COVID-19 pandemic on clinically stable older patients with psychiatric disorders is unclear. This study examined the prevalence of depressive and anxiety symptoms, and their associations with quality of life (QOL) in clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. This was a multicenter, cross-sectional study. Depressive and anxiety symptoms, insomnia, pain, and QOL were assessed with standardized instruments. A total of 1063 patients were included. The prevalence of depressive and anxiety symptoms, and combined depressive and anxiety symptoms were 62.3% (95%CI = 59.4-65.2%), 52.4% (95%CI = 49.3-55.4%), and 45.9% (95%CI = 42.9-48.9%), respectively. Patients with depressive and anxiety symptoms had significantly lower QOL than those without (P < 0.01). Binary logistic regression analyses revealed that having depressive symptoms was positively associated with more severe insomnia (OR = 1.29, P < 0.01) and pain (OR = 1.14, P < 0.01), and was negatively associated with other psychiatric diagnoses (except for major depressive disorder, schizophrenia, and organic mental disorder; OR = 0.50, P < 0.01), while having anxiety symptoms was positively associated with severe physical diseases (OR = 1.57, P = 0.02), poor adherence to treatment (OR = 1.50, P < 0.01), and more severe insomnia (OR = 1.15, P < 0.01) and pain (OR = 1.11, P < 0.01). Having combined depression and anxiety symptoms was positively associated with poor adherence to treatment (OR = 1.42, P = 0.02) and more severe insomnia (OR = 1.19, P < 0.01) and pain (OR = 1.15, P < 0.01), and was negatively associated with the diagnosis of schizophrenia (OR = 0.50, P = 0.04) and others (OR = 0.53, P < 0.01). Depressive and anxiety symptoms were common in clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. Considering the negative impact of these symptoms on QOL, regular screening and appropriate treatment are recommended for

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic is associated with increased risk of insomnia symptoms (insomnia hereafter) in health-care professionals. Network analysis is a novel approach in linking mechanisms at the symptom level. The aim of this study was to characterize the insomnia network structure in mental health professionals during the COVID-19 pandemic. PATIENTS AND METHODS: A total of 10,516 mental health professionals were recruited from psychiatric hospitals or psychiatric units of general hospitals nationwide between March 15 and March 20, 2020. Insomnia was assessed with the insomnia severity index (ISI). Centrality index (ie, strength) was used to identify symptoms central to the network. The stability of network was examined using a case-dropping bootstrap procedure. The network structures between different genders were also compared. RESULTS: The overall network model showed that the item ISI7 (interference with daytime functioning) was the most central symptom in mental health professionals with the highest strength. The network was robust in stability and accuracy tests. The item ISI4 (sleep dissatisfaction) was connected to the two main clusters of insomnia symptoms (ie, the cluster of nocturnal and daytime symptoms). No significant gender network difference was found. CONCLUSION: Interference with daytime functioning was the most central symptom, suggesting that it may be an important treatment outcome measure for insomnia. Appropriate treatments, such as stimulus control techniques, cognitive behavioral therapy and relaxation training, could be developed. Moreover, addressing sleep satisfaction in treatment could simultaneously ameliorate daytime and nocturnal symptoms.

Mental health problems are common in college students even in the late stage of the coronavirus disease 2019 (COVID-19) outbreak. Network analysis is a novel approach to explore interactions of mental disorders at the symptom level. The aim of this study was to elucidate characteristics of depressive and anxiety symptoms network in college students in the late stage of the COVID-19 outbreak. A total of 3062 college students were included. The seven-item Generalized Anxiety Disorder Scale (GAD-7) and nine-item Patient Health Questionnaire (PHQ-9) were used to measure anxiety and depressive symptoms, respectively. Central symptoms and bridge symptoms were identified based on centrality and bridge centrality indices, respectively. Network stability was examined using the case-dropping procedure. The strongest direct relation was between anxiety symptoms "Nervousness" and "Uncontrollable worry". "Fatigue" has the highest node strength in the anxiety and depression network, followed by "Excessive worry", "Trouble relaxing", and "Uncontrollable worry". "Motor" showed the highest bridge strength, followed by "Feeling afraid" and "Restlessness". The whole network was robust in both stability and accuracy tests. Central symptoms "Fatigue", "Excessive worry", "Trouble relaxing" and "Uncontrollable worry", and critical bridge symptoms "Motor", "Feeling afraid" and "Restlessness" were highlighted in this study. Targeting interventions to these symptoms may be important to effectively alleviate the overall level of anxiety and depressive symptoms in college students.

Background: Vaccination is an important preventative measure against the coronavirus disease 19 (COVID-19) pandemic. To implement vaccination and immunization programs effectively, it is essential to investigate public attitudes toward COVID-19 vaccines. This study examined the attitudes of Chinese college students toward COVID-19 vaccines and their associated factors. Methods: A cross-sectional study was conducted in college students nationwide from December 27, 2020 to January 18, 2021. Attitudes toward COVID-19 vaccines and acceptance of future vaccination programs were assessed. Results: Totally, 2,881 college students participated in this survey; of them, 76.3% (95% CI: 74.8% - 77.9%) were willing to accept a COVID-19 vaccine in the future. Multiple logistic analysis revealed that students living in urban (OR=1.409, 95% CI: 1.152 - 1.724, p=0.001) and those studying health-related courses (OR=1.581, 95% CI: 1.291 - 1.935, p<0.001) were more likely to have a positive attitude toward COVID-19 vaccines. In addition, those who were worried about being infected with COVID-19 (very much vs no, OR=1.690, 95% CI: 1.212-2.356, p=0.002), heard previously about COVID-19 vaccines (OR=1.659, 95% CI: 1.268-2.170, p<0.001), believed that vaccines are safe (Yes vs No, OR=3.570, 95% CI: 1.825-6.980), thought that vaccines can protect people from being infected with COVID-19 (Yes vs No, OR=1.957, 95% CI: 1.286-2.979, p=0.002), and had encouraged their family and friends to have a vaccine (Yes vs No, OR=17.745, 95% CI: 12.271-25.660, p<0.001) had higher acceptance of COVID-19 vaccination. Conclusions: A high rate of acceptance of COVID-19 vaccines was found among Chinese college students. However, vaccine uptake may be reduced by concerns about vaccine safety and efficacy. Alleviating these concerns and enhancing public confidence in vaccines are crucial for future immunization programs against the COVID-19 pandemic.

The coronavirus disease-19 (COVID-19) has spread throughout the world, affecting many vulnerable populations including patients with severe mental illness (SMI). Recent studies have found that patients with SMI compared to the general population could have a greater risk of morbidity and mortality from COVID-19 due to cognitive impairment, poor awareness of risk, and difficulties in complying with infection control measures. Although some researchers have suggested that patients with SMI should be prioritized for COVID-19 vaccination to reduce the risk of infection, this issue remains controversial.

The coronavirus disease 2019 (COVID-19) and Severe Acute Respiratory Syndrome (SARS) are associated with various psychiatric comorbidities. This is a systematic review and meta-analysis comparing the prevalence of psychiatric comorbidities in all subpopulations during the SARS and COVID-19 epidemics. A systematic literature search was conducted in major international (PubMed, EMBASE, Web of Science, PsycINFO) and Chinese (China National Knowledge Internet [CNKI] and Wanfang) databases to identify studies reporting prevalence of psychiatric comorbidities in all subpopulations during the SARS and COVID-19 epidemics. Data analyses were conducted using the Comprehensive Meta-Analysis Version 2.0 (CMA V2.0). Eighty-two studies involving 96,100 participants were included. The overall prevalence of depressive symptoms (depression hereinafter), anxiety symptoms (anxiety hereinafter), stress, distress, insomnia symptoms, post-traumatic stress symptoms (PTSS) and poor mental health during the COVID-19 epidemic were 23.9% (95% CI: 18.4%-30.3%), 23.4% (95% CI: 19.9%-27.3%), 14.2% (95% CI: 8.4%-22.9%), 16.0% (95% CI: 8.4%-28.5%), 26.5% (95% CI: 19.1%-35.5%), 24.9% (95% CI: 11.0%-46.8%), and 19.9% (95% CI: 11.7%-31.9%), respectively. Prevalence of poor mental health was higher in general populations than in health professionals (29.0% vs. 11.6%; Q=10.99, p=0.001). The prevalence of depression, anxiety, PTSS and poor mental health were similar between SARS and COVID-19 epidemics (all p values>0.05). Psychiatric comorbidities were common in different subpopulations during both the SARS and COVID-19 epidemics. Considering the negative impact of psychiatric comorbidities on health and wellbeing, timely screening and appropriate interventions for psychiatric comorbidities should be conducted for subpopulations affected by such serious epidemics.

Aims: Carers of psychiatric patients often suffered from mental and physical burden during the coronavirus disease 2019 (COVID-19) pandemic due to the lack of mental health services. This study investigated the pattern of fatigue and its association with quality of life (QOL) among the carers of patients attending psychiatric emergency services during the COVID-19 pandemic. Methods: In this cross-sectional study, carers of patients attending psychiatric emergency services during the COVID-19 pandemic were consecutively included. Fatigue, insomnia symptoms, depressive symptoms, and QOL were assessed with standardized instruments. Results: A total of 496 participants were included. The prevalence of fatigue was 44.0% (95% CI = 39.6-48.4%). Multivariate logistic regression analysis revealed that fatigue was positively associated with higher education level (OR = 1.92, P < 0.01) and more severe depressive (OR = 1.18, P < 0.01) and insomnia symptoms (OR = 1.11, P < 0.01). ANCOVA analysis revealed that the QOL was significantly lower in carers with fatigue compared with those without (P = 0.03). Conclusions: Fatigue was common among carers of patients attending psychiatric emergency services during the COVID-19 pandemic. Considering the adverse impact of fatigue on QOL and other health outcomes, routine screening and appropriate intervention for fatigue are warranted for this subpopulation.

OBJECTIVE: Mental health professionals are often exposed to workplace violence (WPV) in China. This study examined the prevalence of WPV and the associated factors and quality of life (QOL) among frontline mental health professionals during the COVID-19 pandemic. METHODS: This national survey was carried out between March 15 and March 20, 2020. WPV and QOL were assessed with standardized measures. RESULTS: A total of 10,516 participants were included. The prevalence of overall WPV was 18.5% (95% CI: 17.9%-19.3%), while verbal abuse/threats was 15.8% and physical violence was 8.4%. Multiple logistic regression analysis revealed that male gender (OR = 1.42, p < 0.01), higher educational level (OR = 1.40, p < 0.01), working in tertiary hospitals (OR = 1.33, p < 0.01), caring for COVID-19 patients (OR = 3.10, p < 0.01) and having more severe anxiety symptom (OR = 1.21, p < 0.01) were positively associated with WPV. In contrast, working in inpatient departments (OR = 0.74, p < 0.01), having longer work experience (OR = 0.99, p = 0.03), and being a junior nurse (OR = 0.73, p < 0.01) were negatively associated with WPV. After controlling for the covariates, mental health professionals who experienced WPV had a lower overall QOL compared to those without WPV (F(1, 10515) = 68.28, p < 0.01). CONCLUSION: This study found that WPV was common among mental health professionals in China during the COVID-19 pandemic. Considering the negative impact of WPV on QOL and quality of patient care, appropriate measures to prevent WPV should be developed.

This paper describes the design and post-layout simulations of a 2/3/4- modulus frequency divider circuit, accompanied with an accumulator that controls the division count. The circuit is capable of operating as an integer or as a fractional divider. Key topic of this paper is the merging of div-2/3 and div-3/4 circuits into a single compact circuit that solves an issue of a forbidden state in fractional-division operation. The circuit is designed with 28-nm CMOS technology and the post-layout simulations indicate an operating input frequency range of 0.3–5.4 GHz with 13-bit fractional frequency resolution between division ratios of 2–4. The divider occupies only 40 µm x 30 µm while consuming 2.0 mW at 5.4 GHz input frequency.

In network theory depression is conceptualized as a complex network of individual symptoms that influence each other, and central symptoms in the network have the greatest impact on other symptoms. Clinical features of depression are largely determined by sociocultural context. No previous study examined the network structure of depressive symptoms in Hong Kong residents. The aim of this study was to characterize the depressive symptom network structure in a community adult sample in Hong Kong during the COVID-19 pandemic. A total of 11,072 participants were recruited between 24 March and 20 April 2020. Depressive symptoms were measured using the Patient Health Questionnaire-9. The network structure of depressive symptoms was characterized, and indices of “strength”, “betweenness”, and “closeness” were used to identify symptoms central to the network. Network stability was examined using a case-dropping bootstrap procedure. Guilt, Sad Mood, and Energy symptoms had the highest centrality values. In contrast, Concentration, Suicide, and Sleep had lower centrality values. There were no significant differences in network global strength (p = 0.259), distribution of edge weights (p = 0.73) and individual edge weights (all p values > 0.05 after Holm–Bonferroni corrections) between males and females. Guilt, Sad Mood, and Energy symptoms were central in the depressive symptom network. These central symptoms may be targets for focused treatments and future psychological and neurobiological research to gain novel insight into depression.

The Center for the Built Environment (CBE) Thermal Comfort Tool is a free online tool for thermal comfort calculations and visualizations that complies with the ASHRAE 55–2017, ISO 7730:2005 and EN 16798–1:2019 Standards. It incorporates the major thermal comfort models, including the Predicted Mean Vote (PMV), Standard Effective Temperature (SET), adaptive models, local discomfort models, SolarCal, and dynamic predictive clothing insulation. Our tool also provides dynamic and interactive visualizations of thermal comfort zones. The CBE Thermal Comfort Tool has several practical applications and each year is used by more than 49,000 users worldwide, including engineers, architects, researchers, educators, facility managers and policymakers.

RATIONALE:Upper airway surgery (UAS) is an established treatment for obstructive sleep apnea (OSA) and is reported to lead to a ~40% improvement in OSA severity. UAS has been suggested to improve OSA by increasing the volume of the pharyngeal airway, however the mechanisms of anatomical improvement following UAS have not been well defined. We therefore aimed to compare and quantify pharyngeal airway and anatomical structures before and after UAS using Magnetic Resonance Imaging (MRI) based analysis. METHOD(S):In a prospective study, 18 patients with moderate-severe OSA suitable for UAS (uvulopalatopharyngoplasty +/- nasal surgery +/- tongue channelling) underwent upper airway MRI imaging paired with diagnostic polysomnography at baseline and at least three months after UAS. Volume of the pharyngeal airway and surrounding soft-tissue structures were determined through segmentation using image analysis software (Slicer3D) performed by one investigator blinded to the operative status of the patient (pre-UAS vs. post-UAS). We also compared the differences in baseline volumes between responders (defined by a reduction in apnea-hypopnea index (AHI) >=50% from baseline) and non-responders. RESULT(S):Completed data analysis is available in 15 patients to date. Pre-operative AHI (mean+/-SD) of was not significantly changed after surgery: 37.67+/-26.90 events/hr to 28.37+/-28.37 events/hr (p=0.29). Total pharyngeal airway volume after UAS did not change significantly from baseline: median pre-UAS volume of 15.42 cm3 [IQR 10.90-19.86] vs. post-UAS 13.17 cm3 [IQR 11.44-23.85] (p>0.99). Velopharyngeal airway volume was significantly reduced after UAS in all but three patients: median pre-UAS volume 3.50cm3 [IQR 2.44-4.73] vs. post-UAS volume 2.70cm3 [IQR 2.12-3.80] (p=0.010). We observed a trend for an association between the percentage changes in total airway volume and AHI (r2= 0.22, p= 0.076). Near-significant increases in volume of the parapharyngeal fat pads 7.51 cm3 [IQR 5

Rationale: Recent evidence has demonstrated that the combination of atomoxetine (selective norepinephrine reuptake inhibitor) and oxybutynin (antimuscarinic inhibitor) greatly reduced OSA severity. Conversely, trials using serotonergic agonists have had poor success in reducing OSA severity despite previous studies demonstrating potential mechanistic pathways for improving upper airway patency. Notably, atomoxetine and oxybutynin also did not improve OSA severity when taken alone. It is therefore possible that serotonergic agents also need to be delivered in combination therapy to be efficacious. Moreover, adding a serotonergic component to the noradrenergic and antimuscarinic drug combination may further reduce OSA severity. We therefore aimed to assess the impact that (1) milnacipran and (2) duloxetine (two noradrenergic/serotonergic reuptake inhibitors), in combination with oxybutynin has on OSA severity. Method(s): A randomized, double-blind, 4 way cross-over, placebo-controlled trial in 10 OSA patients was performed with the following drug conditions administered as oral capsules prior to bedtime: 1) milnacipran/oxybutynin combination 50/5mg, 2) duloxetine/oxybutynin combination 60/5mg, 3) oxybutynin 5mg, 4) placebo. Patients received each drug condition separately across four overnight in-lab polysomnography (PSG) studies ~1-week apart. The primary outcome was OSA severity measured by the Apnea/Hypopnea Index (AHI) from overnight PSG. In order to understand how each drug combination altered OSA pathophysiology four key OSA traits (collapsibility, muscle compensation, arousal threshold, loop gain) were measured non-invasively from the PSG validated techniques. Values reported as mean+/-SD Results: All drug combinations did not significantly reduce the overall AHI compared to placebo (p=0.24). Total sleep time was consistent across each condition (p=0.92), although duloxetine/oxybutynin significantly reduced time spent in REM sleep (3.5 [4.15] vs 9.11 [7.71] %to

RATIONALE:Upper airway surgery (UAS) is an established treatment for obstructive sleep apnea (OSA) and is reported to lead to a ~40% improvement in OSA severity. UAS has been suggested to improve OSA by increasing the volume of the pharyngeal airway, however the mechanisms of anatomical improvement following UAS have not been well defined. We therefore aimed to compare and quantify pharyngeal airway and anatomical structures before and after UAS using Magnetic Resonance Imaging (MRI) based analysis. METHOD(S):In a prospective study, 18 patients with moderate-severe OSA suitable for UAS (uvulopalatopharyngoplasty +/- nasal surgery +/- tongue channelling) underwent upper airway MRI imaging paired with diagnostic polysomnography at baseline and at least three months after UAS. Volume of the pharyngeal airway and surrounding soft-tissue structures were determined through segmentation using image analysis software (Slicer3D) performed by one investigator blinded to the operative status of the patient (pre-UAS vs. post-UAS). We also compared the differences in baseline volumes between responders (defined by a reduction in apnea-hypopnea index (AHI) >=50% from baseline) and non-responders. RESULT(S):Completed data analysis is available in 15 patients to date. Pre-operative AHI (mean+/-SD) of was not significantly changed after surgery: 37.67+/-26.90 events/hr to 28.37+/-28.37 events/hr (p=0.29). Total pharyngeal airway volume after UAS did not change significantly from baseline: median pre-UAS volume of 15.42 cm3 [IQR 10.90-19.86] vs. post-UAS 13.17 cm3 [IQR 11.44-23.85] (p>0.99). Velopharyngeal airway volume was significantly reduced after UAS in all but three patients: median pre-UAS volume 3.50cm3 [IQR 2.44-4.73] vs. post-UAS volume 2.70cm3 [IQR 2.12-3.80] (p=0.010). We observed a trend for an association between the percentage changes in total airway volume and AHI (r2= 0.22, p= 0.076). Near-significant increases in volume of the parapharyngeal fat pads 7.51 cm3 [IQR 5

Rationale: Recent evidence has demonstrated that the combination of atomoxetine (selective norepinephrine reuptake inhibitor) and oxybutynin (antimuscarinic inhibitor) greatly reduced OSA severity. Conversely, trials using serotonergic agonists have had poor success in reducing OSA severity despite previous studies demonstrating potential mechanistic pathways for improving upper airway patency. Notably, atomoxetine and oxybutynin also did not improve OSA severity when taken alone. It is therefore possible that serotonergic agents also need to be delivered in combination therapy to be efficacious. Moreover, adding a serotonergic component to the noradrenergic and antimuscarinic drug combination may further reduce OSA severity. We therefore aimed to assess the impact that (1) milnacipran and (2) duloxetine (two noradrenergic/serotonergic reuptake inhibitors), in combination with oxybutynin has on OSA severity. Method(s): A randomized, double-blind, 4 way cross-over, placebo-controlled trial in 10 OSA patients was performed with the following drug conditions administered as oral capsules prior to bedtime: 1) milnacipran/oxybutynin combination 50/5mg, 2) duloxetine/oxybutynin combination 60/5mg, 3) oxybutynin 5mg, 4) placebo. Patients received each drug condition separately across four overnight in-lab polysomnography (PSG) studies ~1-week apart. The primary outcome was OSA severity measured by the Apnea/Hypopnea Index (AHI) from overnight PSG. In order to understand how each drug combination altered OSA pathophysiology four key OSA traits (collapsibility, muscle compensation, arousal threshold, loop gain) were measured non-invasively from the PSG validated techniques. Values reported as mean+/-SD Results: All drug combinations did not significantly reduce the overall AHI compared to placebo (p=0.24). Total sleep time was consistent across each condition (p=0.92), although duloxetine/oxybutynin significantly reduced time spent in REM sleep (3.5 [4.15] vs 9.11 [7.71] %to

Recently, more than 300 Chinese patients with psychiatric disorders were diagnosed with the 2019 novel coronavirus disease (COVID-19). Possible reasons quoted in the report were the lack of caution regarding the COVID-19 outbreak in January and insufficient supplies of protective gear. We outlined major challenges for patients with psychiatric disorders and mental health professionals during the COVID-19 outbreak, and also discussed how to manage these challenges through further mental health service reform in China.

The 2019 novel coronavirus disease (COVID-19) epidemic in China has presented substantial challenges to traditional forms of mental health service delivery. This review summarizes the expert consensus on the mental health treatment and services for severe psychiatric disorders during the COVID-19 outbreak developed by the Chinese Society of Psychiatry and other academic associations. The Expert Recommendations on Managing Patients with Mental Disorders during a Serious Infectious Disease Outbreak (COVID-19) outline the appropriate measures for psychiatric hospitals or psychiatric units in general hospitals, including the delivery of outpatient, inpatient, and community mental health services. The Expert Recommendations on Internet and Telehealth in Psychiatry during Major Public Health Crises (COVID-19) describe the assessment and treatment issues of internet-based mental health services during the COVID-19 outbreak. The expert consensus recommendations provide guidance for mental health professionals in managing psychiatric services during the COVID-19 outbreak in China. The experiences from China in addressing the challenges in the management of major psychiatric disorders may be useful and relevant to other countries who are combating the COVID-19 pandemic.

INTRODUCTION: High risk of mental health problems is associated with Coronavirus Disease 2019 (COVID-19). This study explored the prevalence of depressive symptoms (depression hereafter) and its relationship with quality of life (QOL) in clinically stable patients with COVID-19. METHODS: This was an online survey conducted in COVID-19 patients across five designated isolation hospitals for COVID-19 in Hubei province, China. Depression and QOL were assessed with standardized instruments. RESULTS: A total of 770 participants were included. The prevalence of depression was 43.1% (95%CI: 39.6%-46.6%). Binary logistic regression analysis found that having a family member infected with COVID-19 (OR=1.51, P = 0.01), suffering from severe COVID-19 infection (OR=1.67, P = 0.03), male gender (OR=0.53, P<0.01), and frequent social media use to obtain COVID-19 related information (OR=0.65, P<0.01) were independently associated with depression. Patients with depression had lower QOL than those without. CONCLUSION: Depression is highly prevalent in clinically stable patients with COVID-19. Regular screening and appropriate treatment of depression are urgently warranted for this population.

The Center for the Built Environment (CBE) Thermal Comfort Tool is a free online tool for thermal comfort calculations and visualizations that complies with the ASHRAE 55–2017, ISO 7730:2005 and EN 16798–1:2019 Standards. It incorporates the major thermal comfort models, including the Predicted Mean Vote (PMV), Standard Effective Temperature (SET), adaptive models, local discomfort models, SolarCal, and dynamic predictive clothing insulation. Our tool also provides dynamic and interactive visualizations of thermal comfort zones. The CBE Thermal Comfort Tool has several practical applications and each year is used by more than 49,000 users worldwide, including engineers, architects, researchers, educators, facility managers and policymakers.

This paper describes the design and measurement of an open-loop fractional frequency divider implementation. The fractional divider consists of a multi-modulus integer frequency divider (MMD), a sigma-delta modulator (SDM) and a pipelined phase interpolator. The fractional frequency division is achieved with the MMD and the 13-bit SDM toggling the integer division ratio. The resulting signal is then processed by the phase interpolator which significantly reduces the spurs by 22 dB and generates spectrally clean signal with correct output frequency. The prototype is implemented in 28-nm CMOS technology and it operates within input frequency range of 1.9 GHz–3.5 GHz with fractional division ratio in between 2–3. As an example of the operation, with a setting of an arbitrary division ratio of 2.3164 and input frequency of 2.4 GHz, the output sets correctly to 1.0361 GHz with RMS jitter of 2.1 ps.

Introduction: Obstructive sleep apnoea (OSA) commonly manifests with greater severity in the supine position. Over 60% of patients with OSA have supine predominant OSA (supine apnoea-hypopnoea index [AHI] greater than twice of non-supine AHI) and 25% have supine isolated OSA (non-supine AHI< 5 events/hour). Therefore, for the majority of patients, the proportion of total sleep time in the supine body position necessarily impacts on the severity of OSA assessed by polysomnography (PSG). We previously reported that the proportion of time in the supine position is significantly higher during laboratory PSG compared to habitual sleep. Here we report the interim results of our current study comparing sleeping position during unattended home PSG to habitual sleeping position. Material(s) and Method(s): This is a prospective observational study of patients referred for unattended PSG through our tertiary academic sleep unit. We use the Night ShiftTM positional therapy device to record body position during the unattended PSG and subsequently for up to three additional nights to sample habitual sleeping position. The Night ShiftTM was programmed to record only; the feedback intervention function was disabled. A paired t-test was used to compare the mean difference in proportion of sleep time in the supine position during unattended PSG compared to habitual sleep. We then calculated a modified AHI "corrected" for habitual sleeping position. Night-to-night variability in habitual sleeping position was assessed using a correlation matrix, and a repeated measures one-way ANOVA. Result(s): To date, fifty-two patients have been recruited, out of a target of 79 patients. 38.5% female, age 47 +/- 12.8 years, body mass index 30.9 (range: 27.5-37.5) kg/m2. Median total AHI 19 (range: 3.2-27.9) events/hour, supine AHI 22 (0.9-45.3) events/hour, non-supine AHI 9.4 (1.3-24.9) events/hour. Fifteen patients (29.4%) had supine predominant OSA and 1 (2%) had supine isolated OSA. Proportion o

As boron nitride nanotubes (BNNTs) find increased use in numerous applications, potential adverse health effects of BNNT exposure are a growing concern. Current in vitro cytotoxicity studies on BNNTs are inconsistent and even contradictory, likely due to the lack of reference materials, standardized characterization methods and measurement protocols. New approaches, particularly with the potential to reliably relate in vitro to in vivo studies, are critically needed. This work introduces a novel atomic force microscopy (AFM)-based cardiomyocyte assay that reliably assesses the cytotoxicity of a well-characterized boron nitride nanotube reference material, code named BNNT-1. High energy probe sonication was used to modify and control the length of BNNT-1. The polymer polyethylenimine (PEI) was used concurrently with sonication to produce stable, aqueous dispersions of BNNT-1. These dispersions were used to perform a systematic analysis on both the length and height of BNNT-1 via a correlated characterization approach of dynamic light scattering (DLS) and AFM. Cytotoxicity studies using the novel cardiomyocyte AFM model were in agreement with traditional colorimetric cell metabolic assays, both revealing a correlation between tube length and cytotoxicity with longer tubes having higher cytotoxicity. In addition to the size-dependent cytotoxicity, it was found that BNNT-1 exhibits concentration and cell-line dependent cytotoxic effects.