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Background: Myotonic dystrophy type 1 (DM1) is associated with progressive conduction disease. Furthermore, DM1 patients are at risk ventricular arrhythmias (VAs), although prediction remains difficult. The 2022 Heart Rhythm Expert Consensus Statement gives a IIb recommendation to the use of electrophysiology study (EPS) to risk-stratify patients for VAs. The utility of EPS in predicting the development of VAs, however, has not been explored in this patient population. Objective: The study sought to examine the natural history of DM1 patients with positive and negative ventricular stimulation (v-stim) during EPS. Methods: Patients with a history of DM1 undergoing EPS with associated v-stim from 2008 to present were retrospectively identified. Results: From 2008 to 2022, 26 consecutive DM1 patients presented for EPS with v-stim. Four v-stim protocols were positive for sustained or hemodynamically significant ventricular tachycardia (VT), one of which was induced with 600 doubles, the others with triple extrastimuli. A total of 22 of 26 subjects received a device implant, with 18 receiving permanent pacemakers and 4 implantable cardioverter-defibrillators. All 4 of the patients with positive v-stims underwent ICD implantation. After a mean of 5.7 years of follow-up, 7 patients had sustained VT, 6 of whom had negative v-stims. Of the 4 patients with positive v-stims, only 1 developed sustained VT in follow-up. Other than baseline QT interval at time of EPS, no baseline characteristics were significantly different between patients with and without subsequent VT. Conclusion: In this single center, v-stim in DM1 patients did not predict clinical VAs, as a vast majority of DM1 patients who developed VAs had negative v-stims.

We developed and applied a novel approach for shape agnostic detection of multiscale flaws in laser powder bed fusion (LPBF) additive manufacturing using heterogenous in-situ sensor data. Flaws in LPBF range from porosity at the micro-scale (< 100 µm), layer related inconsistencies at the meso-scale (100 µm to 1 mm) and geometry-related flaws at the macroscale (> 1 mm). Existing data-driven models are primarily focused on detecting a specific type of LPBF flaw using signals from one type of sensor. Such approaches, which are trained on data from simple cuboid and cylindrical-shaped coupons, have met limited success when used for detecting multiscale flaws in complex LPBF parts. The objective of this work is to develop a heterogenous sensor data fusion approach capable of detecting multiscale flaws across different LPBF part geometries and build conditions. Accordingly, data from an infrared camera, spatter imaging camera, and optical powder bed imaging camera were acquired across separate builds with differing part geometries and orientations (Inconel 718). Spectral graph-based process signatures were extracted from this heterogeneous thermo-optical sensor data and used as inputs to simple machine learning models. The approach detected porosity, layer-level distortion, and geometry-related flaws with statistical fidelity exceeding 93% (F-score).

Abstract The veined squid, Loligo forbesii Steenstrup, 1856, occurs at the European Shelf areas including the Azores and represents a valuable resource for the European commercial fishery in the North East Atlantic. However, very little is known about its population structure and phylogeography. This lack of knowledge also impedes the development of sustainable fishery management for this species. The present study combined the use of two types of markers that retrieve patterns of gene flow in different time spans; the analysis of 16 nuclear microsatellites and sequencing of the mitochondrial cytochrome oxidase subunit I (COI). Whereas the high mutation rate of microsatellites allows the description of recent patterns of connectivity in species, the lower mutation rate of COI provides phylogeographic patterns on a longer timescale. A total of 347 individuals of L. forbesii were investigated from nearly the entire distribution range of the species, including the North East Atlantic Shelf, the Azores and the Mediterranean. Individuals from the Western and Eastern Mediterranean Sea have never been included in a genetic study before. We were able to analyse COI sequences from all 12 sampling areas and define three clades of L. forbesii. Due to our large sampling area, we are presenting 13 COI-haplotypes that were previously unknown. The microsatellite analysis does not include the Azores but three main clades could be identified at the remaining 11 sampling sites. Low FST values indicate gene flow over large geographical distances. However, the genetically significant differences and an additional slight grouping in the microsatellite structure reveal that geographical barriers seem to influence the population structure and reduce gene flow. Furthermore, both markers provide strong evidence that the observed phylogeographic pattern reflects the geographical history of the Azores and the Mediterranean Sea.

BackgroundDespite the numerous studies evaluating various rhythm control strategies for atrial fibrillation (AF), determination of the optimal strategy in a single patient is often based on trial and error, with no one-size-fits-all approach based on international guidelines/recommendations. The decision, therefore, remains personal and lends itself well to help from a clinical decision support system, specifically one guided by artificial intelligence (AI). QRhythm utilizes a 2-stage machine learning (ML) model to identify the optimal rhythm management strategy in a given patient based on a set of clinical factors, in which the model first uses supervised learning to predict the actions of an expert clinician and identifies the best strategy through reinforcement learning to obtain the best clinical outcome—a composite of symptomatic recurrence, hospitalization, and stroke. ObjectiveWe qualitatively evaluated a novel, AI-based, clinical decision support system (CDSS) for AF rhythm management, called QRhythm, which uses both supervised and reinforcement learning to recommend either a rate control or one of 3 types of rhythm control strategies—external cardioversion, antiarrhythmic medication, or ablation—based on individual patient characteristics. MethodsThirty-three clinicians, including cardiology attendings and fellows and internal medicine attendings and residents, performed an assessment of QRhythm, followed by a survey to assess relative comfort with automated CDSS in rhythm management and to examine areas for future development. ResultsThe 33 providers were surveyed with training levels ranging from resident to fellow to attending. Of the characteristics of the app surveyed, safety was most important to providers, with an average importance rating of 4.7 out of 5 (SD 0.72). This priority was followed by clinical integrity (a desire for the advice provided to make clinical sense; importance rating 4.5, SD 0.9), backward interpretability (transparency in the population used to create the algorithm; importance rating 4.3, SD 0.65), transparency of the algorithm (reasoning underlying the decisions made; importance rating 4.3, SD 0.88), and provider autonomy (the ability to challenge the decisions made by the model; importance rating 3.85, SD 0.83). Providers who used the app ranked the integrity of recommendations as their highest concern with ongoing clinical use of the model, followed by efficacy of the application and patient data security. Trust in the app varied; 1 (17%) provider responded that they somewhat disagreed with the statement, “I trust the recommendations provided by the QRhythm app,” 2 (33%) providers responded with neutrality to the statement, and 3 (50%) somewhat agreed with the statement. ConclusionsSafety of ML applications was the highest priority of the providers surveyed, and trust of such models remains varied. Widespread clinical acceptance of ML in health care is dependent on how much providers trust the algorithms. Building this trust involves ensuring transparency and interpretability of the model.

Background: In 2020, 6% of Scotland's adult population was ≥80 years. Advancements in care mean improved chances of survival at 6-months for older adults following injury to the brain or spine. The Covid-19 pandemic also resulted in local and national policies aimed at protecting the elderly. We sought to evaluate referral patterns and outcomes for patients ≥80 years referred to our institution during this period. Objective: To evaluate referral patterns and outcomes for patients ≥80 years referred to our institution both before and during the coronavirus pandemic. Design: Retrospective observational cohort study. Setting: Tertiary care in a developing major trauma centre (Queen Elizabeth University Hospital, Glasgow). Participants: All patients ≥80 years referred to the on-call neurosurgical service over two four-month periods before (2016–17; n = 1573) and after the onset of Covid-19 (2020; n = 2014). Methods: Data on demographics, ASA, diagnosis and referral decision were collected. 30-day and 6-month mortality and functional independence were assessed. Results: 246 (before) and 335 (during Covid-19) referred patients were ≥80 years. No gender bias. A significant increase (17%) in acute trauma was seen during the pandemic months. Fewer older adults were transferred (6% to 2% Covid-19) for specialist care, most commonly for chronic subdural haematoma. Most were alive, home and independent at 6 months (47% pre and 63% during Covid-19). Conclusions: Octogenarians feature disproportionately in acute adult neurosurgical referrals. In our department, local and national responses to the Covid-19 pandemic did not appear to influence this. Robust evidence of neurosurgical outcomes in the older adult is required to fairly distribute resources for our ageing population, but decisions must not be based on age alone.

Objective To determine whether and how cognitive assessment data should be included in a report for patients with SLE and their providers.Methods Leveraging experiences from prior studies, we created a cognitive report that included a hypothetical patient’s results on tests of multiple domains based on the NIH Toolbox Fluid Cognition Battery. In focus groups that comprised patients with SLE (two groups) and their providers (two groups), feedback was sought on the presentation of results as well as the potential value of the report in the clinical setting.Results Feedback regarding the presentation of the report was generally positive. Both patients with SLE and their providers liked its simple graphics and use of a colour-gradated scale to indicate performance. However, both groups stressed the importance of using non-stigmatising language in describing results. Several potential purposes of the report, including distinguishing cognitive versus other issues, explaining cognitive challenges, improving patient–provider interactions, guiding decision-making, improving functioning or preventing impairment and tracking cognitive function over time, were noted by the participants. Potential barriers, such as inadequate clinical staffing or time and lack of potential treatments for identified issues, were also discussed.Conclusion In this exploratory study, we found that both patients with SLE and their providers were receptive to the idea of a patient-friendly report of cognitive test results. This study provides important information to guide future pragmatic research to optimise the delivery of cognitive information to patients with SLE.

Twin–twin interactions are an important component of the microstructural evolution of hexagonal close-packed metals undergoing plasticity. These interactions are prevalent because of the predominance of twinning due to limited easy slip modes. Despite their importance, the complexities of the atomic-scale behavior of interacting twins has limited robust characterization. Using interfacial defect theory, we developed a three-dimensional model of twin–twin interactions, double twinning and other complex interfacial reactions that occur between twins acting on different interface planes. Using molecular dynamics, {1122} and {1121} twins in titanium were activated and produced facets, twin–twin interactions and double twins that we characterized with our model. The results showed excellent agreement between the molecular dynamics results and the model. Surprisingly, some highly ordered and mobile boundaries can be produced by these complex reactions, which could provide important insights for higher scale models of plasticity.

In the title compound, C17H15N3O3, the plane of the pyrrolidone ring is inclined at an angle of 59.791 (2)° to that of the azobenzene segment, which adopts a configuration close to planar. In the crystal, molecules are oriented pairwise by (2-oxopyrrolidin-3-yl)oxy moieties at an angle of 76.257 (3)°, linked by hydrogen bonds and π-stacking interactions, forming zigzag supramolecular chains parallel to [010] further linked via additional C—H...π interactions.

Introduction: Integration of point of care ultrasound (POCUS) into clinical clerkships in a statewide campus is challenging. The objective of this paper was to describe the implementation and evaluation of a POCUS curriculum that was added to Emergency Medicine (EM) and Obstetrics and Gynecology (OB/GYN) core clinical rotations in a distributed campus undergraduate medical education (UME) model. The authors declared no conflicts of interest. The study was reviewed by the institutional IRB and determined to be exempt. Methods: This was a descriptive study of the implementation and evaluation of POCUS into two clinical clerkships. In this paper, we describe the development of a grading rubric, educational design, and image transfer process used to evaluate student performance. Results: Implementation occurred in step wise fashion. In the EM clerkship between 2016 and 2018, 395 students participated with a 100% completion rate. In the OB/GYN clerkship, 2017-2018, 186 students completed the clerkship all but one successfully completing the assignment. Conclusion: This pilot project demonstrated the successful implementation of a POCUS curriculum in two clinical clerkships in an UME distributed campus model.

Frailty prevalence in older adults has been reported but is largely unknown in middle-aged adults. We determined the prevalence of frailty indicators among middle-aged and older adults from a general Swiss population characterized by universal health insurance coverage and assessed the determinants of frailty with a special focus on socioeconomic status. Participants aged 50 and more from the population-based 2006–2010 Bus Santé study were included (N = 2,930). Four frailty indicators (weakness, shrinking, exhaustion, and low activity) were measured according to standard definitions. Multivariate logistic regressions were used to determine associations. Overall, 63.5%, 28.7%, and 7.8% participants presented no frailty indicators, one frailty indicator, and two or more frailty indicators, respectively. Among middle-aged participants (50–65 years), 75.1%, 22.2%, and 2.7% presented 0, 1, and 2 or more frailty indicators. The number of frailty indicators was positively associated with age, hypertension, and current smoking and negatively associated with male gender, body mass index, waist-to-hip ratio, and serum total cholesterol level. Lower income level but not education was associated with higher number of frailty indicators. Frailty indicators are frequently encountered in both older and middle-aged adults from the Swiss general population. Despite universal health insurance coverage, household income is independently associated with frailty.

This research compares the performance of bottom-up, self-motivated behavioral interventions with top-down interventions targeted at controlling an "Influenza-like-illness". Both types of interventions use a variant of the ring strategy. In the first case, when the fraction of a person's direct contacts who are diagnosed exceeds a threshold, that person decides to seek prophylaxis, e.g. vaccine or antivirals; in the second case, we consider two intervention protocols, denoted Block and School: when a fraction of people who are diagnosed in a Census Block (resp., School) exceeds the threshold, prophylax the entire Block (resp., School). Results show that the bottom-up strategy outperforms the top-down strategies under our parameter settings. Even in situations where the Block strategy reduces the overall attack rate well, it incurs a much higher cost. These findings lend credence to the notion that if people used antivirals effectively, making them available quickly on demand to private citizens could be a very effective way to control an outbreak.

A class of finite discrete dynamical systems, called Sequential Dynamical Systems (SDSs), was proposed in [BMR99,BR99] as an abstract model of computer simulations. Here, we address some questions concerning two special types of the SDS configurations, namely Garden of Eden and Fixed Point configurations. A configuration $C$ of an SDS is a Garden of Eden (GE) configuration if it cannot be reached from any configuration. A necessary and sufficient condition for the non-existence of GE configurations in SDSs whose state values are from a finite domain was provided in [MR00]. We show this condition is sufficient but not necessary for SDSs whose state values are drawn from an infinite domain. We also present results that relate the existence of GE configurations to other properties of an SDS. A configuration $C$ of an SDS is a fixed point if the transition out of $C$ is to $C$ itself. The FIXED POINT EXISTENCE (or FPE) problem is to determine whether a given SDS has a fixed point. We show thatthe FPE problem is NP-complete even for some simple classes of SDSs (e.g., SDSs in which each local transition function is from the set{NAND, XNOR}). We also identify several classes of SDSs (e.g., SDSs with linear or monotone local transition functions) for which the FPE problem can be solved efficiently.

Background: Racial inequality in functional trajectories has been well documented in the U.S. civilian population but has not been explored among Veterans. Our objectives were to: (1) assess how functional trajectories differed for Black and White Veterans aged ≥50 and (2) explore how socioeconomic, psychosocial, and health‐related factors altered the relationship between race and function. Methods: We conducted a prospective, longitudinal analysis using the 2006–2016 Health and Retirement Study. The study cohort included 3700 Veterans who self‐identified as Black or White, responded to baseline psychosocial questionnaires, and were community‐dwelling on first observation. We used stepwise and stratified linear mixed effects models of biannually assessed functional limitations. The outcome measure was as a count of functional limitations. Race was measured as respondent self‐identification as Black or White. Demographic measures included gender and age. Socioeconomic resources included partnership status, education, income, and wealth. Psychosocial stressors included exposure to day‐to‐day and major discrimination, traumatic life events, stressful life events, and financial strain. Health measures included chronic and mental health diagnoses, smoking, rurality, and use of Veterans Affairs services. Results: Black Veterans developed functional limitations at earlier ages and experienced faster functional decline than White Veterans between the ages of 50 and 70, with convergence occurring at age 85. Once we accounted for economic resources and psychosocial stressors in multivariable analyses, the association between race and the number of functional limitations was no longer statistically significant. Lower wealth, greater financial strain, and traumatic life events were significantly associated with functional decline. Conclusions: Health systems should consider how to track Veterans' function earlier in the life course to ensure that Black Veterans are able to get timely access to services that may slow premature functional decline. Providers may benefit from training about the role of economic resources and psychosocial stressors in physical health outcomes. [ABSTRACT FROM AUTHOR]

The last several decades have witnessed the emergence of evidence-based medicine as the dominant paradigm for medical teaching, research and practice. Under an evidence-based approach, populations rather than individuals become the primary focus of investigation. Treatment priorities are largely shaped by the availability, relevance and quality of evidence and study outcomes and results are assumed to have more or less universal significance based on their implications at the population level. However, population-level treatment goals do not always align with what matters the most to individual patients-who may weigh the risks, benefits and harms of recommended treatments quite differently. In this article we describe the rise of evidence-based medicine in historical context. We discuss limitations of this approach for supporting realworld treatment decisions-especially in older adults with confluent comorbidity, functional impairment and/or limited life expectancy-and we describe the emergence of more patientcentered paradigms to address these limitations. We explain how the principles of evidence-based medicine have helped to shape contemporary approaches to defining, classifying and managing patients with chronic kidney disease. We discuss the limitations of this approach and the potential value of a more patient-centered paradigm, with a particular focus on the care of older adults with this condition. We conclude by outlining ways in which the evidence-base might be reconfigured to better support real-world treatment decisions in individual patients and summarize relevant ongoing initiatives. [ABSTRACT FROM AUTHOR]

Frailty prevalence in older adults has been reported but is largely unknown in middle-aged adults. We determined the prevalence of frailty indicators among middle-aged and older adults from a general Swiss population characterized by universal health insurance coverage and assessed the determinants of frailty with a special focus on socioeconomic status. Participants aged 50 and more from the population-based 2006-2010 Bus Sante study were included (N = 2,930). Four frailty indicators (weakness, shrinking, exhaustion, and low activity) were measured according to standard definitions. Multivariate logistic regressions were used to determine associations. Overall, 63.5%, 28.7%, and 7.8% participants presented no frailty indicators, one frailty indicator, and two or more frailty indicators, respectively. Among middle-aged participants (50-65 years), 75.1%, 22.2%, and 2.7% presented 0,1, and 2 or more frailty indicators. The number of frailty indicators was positively associated with age, hypertension, and current smoking and negatively associated with male gender, body mass index, waist-to-hip ratio, and serum total cholesterol level. Lower income level but not education was associated with higher number of frailty indicators. Frailty indicators are frequently encountered in both older and middle-aged adults from the Swiss general population. Despite universal health insurance coverage, household income is independently associated with frailty. [ABSTRACT FROM AUTHOR]

Objective: To determine whether and how cognitive assessment data should be included in a report for patients with SLE and their providers., Methods: Leveraging experiences from prior studies, we created a cognitive report that included a hypothetical patient's results on tests of multiple domains based on the NIH Toolbox Fluid Cognition Battery. In focus groups that comprised patients with SLE (two groups) and their providers (two groups), feedback was sought on the presentation of results as well as the potential value of the report in the clinical setting., Results: Feedback regarding the presentation of the report was generally positive. Both patients with SLE and their providers liked its simple graphics and use of a colour-gradated scale to indicate performance. However, both groups stressed the importance of using non-stigmatising language in describing results. Several potential purposes of the report, including distinguishing cognitive versus other issues, explaining cognitive challenges, improving patient-provider interactions, guiding decision-making, improving functioning or preventing impairment and tracking cognitive function over time, were noted by the participants. Potential barriers, such as inadequate clinical staffing or time and lack of potential treatments for identified issues, were also discussed., Conclusion: In this exploratory study, we found that both patients with SLE and their providers were receptive to the idea of a patient-friendly report of cognitive test results. This study provides important information to guide future pragmatic research to optimise the delivery of cognitive information to patients with SLE., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)