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Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended, in patients with an On-X mechanical mitral valve.After On-X mechanical mitral valve replacement followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR 2.0 to 2.5) or standard-dose warfarin (target INR 2.5 to 3.5). All patients were prescribed aspirin 81 mg daily and encouraged to use home INR testing. The primary endpoint was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin.Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P.001) in the low-dose and standard-dose warfarin groups, respectively. Primary endpoint rates were 11.9%/patient-year in the low-dose group and 12.0%/patient-year in the standard-dose group (difference -0.07, 95% confidence intervals: -3.40, 3.26). The confidence interval exceeded 1.5%, thus noninferiority was not achieved. Rates (%/patient-year) of the individual components of the primary endpoint were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding.Compared to standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary endpoint. (PROACT Clinicaltrials.gov number, NCT00291525).

International audience; Fossil endocasts record features of brains from the past: size, shape, vasculature, and gyrification. These data, alongside experimental and comparative evidence, are needed to resolve questions about brain energetics, cognitive specializations, and developmental plasticity. Through the application of interdisciplinary techniques to the fossil record, paleoneurology has been leading major innovations. Neuroimaging is shedding light on fossil brain organization and behaviors. Inferences about the development and physiology of the brains of extinct species can be experimentally investigated through brain organoids and transgenic models based on ancient DNA. Phylogenetic comparative methods integrate data across species and associate genotypes to phenotypes, and brains to behaviors. Meanwhile, fossil and archeological discoveries continuously contribute new knowledge. Through cooperation, the scientific community can accelerate knowledge acquisition. Sharing digitized museum collections improves the availability of rare fossils and artifacts. Comparative neuroanatomical data are available through online databases, along with tools for their measurement and analysis. In the context of these advances, the paleoneurological record provides ample opportunity for future research. Biomedical and ecological sciences can benefit from paleoneurology’s approach to understanding the mind as well as its novel research pipelines that establish connections between neuroanatomy, genes and behavior.

Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement.From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients.Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Introduction: Several investigations have examined utilizing inertial measurement units (IMU) to estimate ground reaction force (GRF) during exercise. The purpose of this investigation was to determine the effect of inertial measurement units location on the estimation of ground reaction force during vertical jumping.Methods: Eight male subjects completed a series of ten countermovement jumps on a force plate (FP). The subjects had an inertial measurement units attached to the sacrum, back and chest. Ground reaction force was estimated from data from the individual inertial measurement units and by using a two-segment model and combined sensor approach.Results: The peak ground reaction force values for the sacrum, back, chest and combined inertial measurement units were 1,792 ± 278 N, 1,850 ± 341 N, 2,054 ± 346 N and 1,812 ± 323 N, respectively. The sacral inertial measurement units achieved the smallest differences for ground reaction force estimates providing a root mean square error (RMSE) between 88 N and 360 N. The inertial measurement units on the sacrum also showed significant correlations in peak ground reaction force (p < 0.001) and average ground reaction force (p < 0.001) using the Bland-Altman 95% Limits of Agreement (LOA) when in comparison to the force plate.Discussion: Based on assessment of bias, Limits of Agreement, and RMSE, the inertial measurement units located on the sacrum appears to be the best placement to estimate both peak and average ground reaction force during jumping.

Complex sensor arrays prohibit practical deployment of existing wearables-based algorithms for free-living analysis of muscle and joint mechanics. Machine learning techniques have been proposed as a potential solution, however, they are less interpretable and generalizable when compared to physics-based techniques. Herein, we propose a hybrid method utilizing inertial sensor- and electromyography (EMG)-driven simulation of muscle contraction to characterize knee joint and muscle mechanics during walking gait. Machine learning is used only to map a subset of measured muscle excitations to a full set thereby reducing the number of required sensors. We demonstrate the utility of the approach for estimating net knee flexion moment (KFM) as well as individual muscle moment and work during the stance phase of gait across nine unimpaired subjects. Across all subjects, KFM was estimated with 0.91 %BW•H RMSE and strong correlations (r = 0.87) compared to ground truth inverse dynamics analysis. Estimates of individual muscle moments were strongly correlated (r = 0.81-0.99) with a reference EMG-driven technique using optical motion capture and a full set of electrodes as were estimates of muscle work (r = 0.88-0.99). Implementation of the proposed technique in the current work included instrumenting only three muscles with surface electrodes (lateral and medial gastrocnemius and vastus medialis) and both the thigh and shank segments with inertial sensors. These sensor locations permit instrumentation of a knee brace/sleeve facilitating a practically deployable mechanism for monitoring muscle and joint mechanics with performance comparable to the current state-of-the-art.

The true lender rule issued by the Office of the Comptroller of the Currency (OCC) briefly provided a uniform standard that could be applied to determine when a national bank is acting as a lender when it partners with other service providers. The rule was lauded for its objective standard that respected the form of legal documentation. The fintech marketplace lending platforms and banks that have been doing business for years under a bank partnership model viewed the rule as a welcome sign that the OCC did not support state efforts to recast the marketplace lending platforms as the true lender as a way to impose state law usury rules against national banks. Then Congress invalidated the rule under the Congressional Review Act (CRA) within six months of its effective date. Did the bank partnership model take one step forward and two steps back? In this article, we explore “true lender” issues, existing litigation and regulatory developments, and the implications following the invalidation of the rule. Key Findings ▪ If true lender arguments prevail and a nonbank is deemed the lender, federal preemption is inapplicable and state law limitations will apply, which in several states renders the loans unenforceable and requires repayments to the borrower. ▪ The invalidation of the true lender rule leaves market participants with the same lack of a uniform standard that existed before the rule and it creates uncertainty in what should be an efficient market for providing borrowers access to capital. ▪ We expect new legislation (e.g., recently enacted laws in Maine and Illinois) and new regulatory efforts aimed at finding that banks working with fintechs are not the true lenders and seeking to hold fintechs and their assignees liable for usury.

Industry standards for over-the-air testing of LTE MIMO devices have used multi-probe anechoic chamber based systems, also known as the boundary array method, to evaluate device performance in a spatially static environment. The spatial distribution of clusters in the chosen channel models, such as the SCME Urban Micro and Urban Macro channel models, are fixed, and the only geometric variation relative to the device under test is accomplished by physically rotating the device in the generated test environment. For 5G FR1 testing, 3GPP has adopted a similar approach. However, in an effort to meet the desire of the North American cellular network operators to better understand the behavior of a device on a realistic network, the CTIA MIMO OTA working group is developing a test plan based on the use of dynamic channel models that vary the spatial configuration as a function of time, and allowing the communication tester base station emulator to perform link adaptation, allowing the device to choose the best MIMO or SISO diversity mode and data rate for a given channel condition. This paper will discuss the design considerations associated with developing this new channel model and the related test system requirements.

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This work proposes a proof of concept along with a prototype of a multi-agent autonomous drone system that can be used to detect, and capture a intruding adversarial drone. The functional Counter Unmanned Aerial System (CUAS) prototype is used to convey the feasibility of a persistent multi-agent aerial protection and apprehension system by demonstrating important features of the mission through both simulation and field testing.

Bat box microclimates vary spatially and temporally in temperature suitability. This heterogeneity subjects roosting bats to a variety of thermoregulatory challenges (e.g. heat and cold stress). Understanding how different bat box designs, landscape placements, weather and bat use affect temperature suitability and energy expenditure is critical to promote safe and beneficial artificial roosting habitat for species of conservation concern. From April to September 2019, we systematically deployed 480 temperature dataloggers among 40 rocket box style bat boxes of 5 designs and regularly monitored bat abundance. We used bioenergetic models to assess energy costs for endothermic and heterothermic bats and modelled the overheating risk for each box as a function of design, placement, bat abundance and weather. For endothermic bats, predicted daily energy expenditure was lower for solar-exposed placements, large group sizes and a box design with enhanced thermal mass. For heterothermic bats, shaded landscape placements were the most energetically beneficial and bat box design was not important, because all designs generally offered microclimates suitable for torpor use at some position within the box. Overheating risk was highest for solar-exposed landscape placements and for designs lacking modifications to buffer temperature, and with increasing bat abundance, increasing ambient temperature and slower wind speeds. The external water jacket design, with the greatest thermal mass, concomitantly decreased overheating risk and endothermic energy expenditure. By assessing bat box suitability from two physiological perspectives, we provide a robust method to assess the conservation value of bat box design and placement strategies. We recommend future studies examine how changing thermal mass and conductance can be used to diminish overheating risk while also enhancing the effects of social thermoregulation for bat box users.

Field-based sprint performance assessments rely on metrics derived from a simple model of sprinting dynamics parameterized by 2 constants, v0 and τ, which indicate a sprinter’s maximal theoretical ...

Falls are frequent and associated with morbidity in persons with multiple sclerosis (PwMS). Symptoms of MS fluctuate, and standard biannual clinical visits cannot capture these fluctuations. Remote monitoring techniques that leverage wearable sensors have recently emerged as an approach sensitive to disease variability. Previous research has shown that fall risk can be identified from walking data collected by wearable sensors in controlled laboratory conditions however this data may not be generalizable to variable home environments. To investigate fall risk and daily activity performance from remote data, we introduce a new open-source dataset featuring data collected from 38 PwMS, 21 of whom are identified as fallers and 17 as non-fallers based on their six-month fall history. This dataset contains inertial-measurement-unit data from eleven body locations collected in the laboratory, patient-reported surveys and neurological assessments, and two days of free-living sensor data from the chest and right thigh. Six-month (n = 28) and one-year repeat assessment (n = 15) data are also available for some patients. To demonstrate the utility of these data, we explore the use of free-living walking bouts for characterizing fall risk in PwMS, compare these data to those collected in controlled environments, and examine the impact of bout duration on gait parameters and fall risk estimates. Both gait parameters and fall risk classification performance were found to change with bout duration. Deep learning models outperformed feature-based models using home data; the best performance was observed with all bouts for deep-learning and short bouts for feature-based models when evaluating performance on individual bouts. Overall, short duration free-living walking bouts were found to be the least similar to laboratory walking, longer duration free-living walking bouts provided more significant differences between fallers and non-fallers, and an aggregation of all free-living walking bouts yields the best performance in fall risk classification.

Wearable sensors facilitate the evaluation of gait and balance impairment in the free-living environment, often with observation periods spanning weeks, months, and even years. Data supporting the minimal duration of sensor wear, which is necessary to capture representative variability in impairment measures, are needed to balance patient burden, data quality, and study cost. Prior investigations have examined the duration required for resolving a variety of movement variables (e.g., gait speed, sit-to-stand tests), but these studies use differing methodologies and have only examined a small subset of potential measures of gait and balance impairment. Notably, postural sway measures have not yet been considered in these analyses. Here, we propose a three-level framework for examining this problem. Difference testing and intra-class correlations (ICC) are used to examine the agreement in features computed from potential wear durations (levels one and two). The association between features and established patient reported outcomes at each wear duration is also considered (level three) for determining the necessary wear duration. Utilizing wearable accelerometer data continuously collected from 22 persons with multiple sclerosis (PwMS) for 6 weeks, this framework suggests that 2 to 3 days of monitoring may be sufficient to capture most of the variability in gait and sway; however, longer periods (e.g., 3 to 6 days) may be needed to establish strong correlations to patient-reported clinical measures. Regression analysis indicates that the required wear duration depends on both the observation frequency and variability of the measure being considered. This approach provides a framework for evaluating wear duration as one aspect of the comprehensive assessment, which is necessary to ensure that wearable sensor-based methods for capturing gait and balance impairment in the free-living environment are fit for purpose. Published version

Background Panic attacks (PAs) are an impairing mental health problem that affects >11% of adults every year. PAs are episodic, and it is difficult to predict when or where they may occur; thus, they are challenging to study and treat. Objective The aim of this study is to present PanicMechanic, a novel mobile health app that captures heart rate–based data and delivers biofeedback during PAs. Methods In our first analysis, we leveraged this tool to capture profiles of real-world PAs in the largest sample to date (148 attacks from 50 users). In our second analysis, we present the results from a pilot study to assess the usefulness of PanicMechanic as a PA intervention (N=18). Results The results demonstrate that heart rate fluctuates by about 15 beats per minute during a PA and takes approximately 30 seconds to return to baseline from peak, cycling approximately 4 times during each attack despite the consistently decreasing anxiety ratings. Thoughts about health were the most common trigger and potential lifestyle contributors include slightly worse stress, sleep, and eating habits and slightly less exercise and drug or alcohol consumption than typical. Conclusions The pilot study revealed that PanicMechanic is largely feasible to use but would be made more so with modifications to the app and the integration of consumer wearables. Similarly, participants found PanicMechanic useful, with 94% (15/16) indicating that they would recommend PanicMechanic to others who have PAs. These results highlight the need for future development and a controlled trial to establish the effectiveness of this digital therapeutic for preventing PAs.

Human lower-limb kinematic measurements are critical for many applications including gait analysis, enhancing athletic performance, reducing or monitoring injury risk, augmenting warfighter performance, and monitoring elderly fall risk, among others. We present a new method to estimate lower-limb kinematics using an error-state Kalman filter that utilizes an array of body-worn inertial measurement units (IMUs) and four kinematic constraints. We evaluate the method on a simplified 3-body model of the lower limbs (pelvis and two legs) during walking using data from simulation and experiment. Evaluation on this 3-body model permits direct evaluation of the ErKF method without several confounding error sources from human subjects (e.g., soft tissue artefacts and determination of anatomical frames). RMS differences for the three estimated hip joint angles all remain below 0.2 degrees compared to simulation and 1.4 degrees compared to experimental optical motion capture (MOCAP). RMS differences for stride length and step width remain within 1% and 4%, respectively compared to simulation and 7% and 5%, respectively compared to experiment (MOCAP). The results are particularly important because they foretell future success in advancing this approach to more complex models for human movement. In particular, our future work aims to extend this approach to a 7-body model of the human lower limbs composed of the pelvis, thighs, shanks, and feet.

Estimation of muscle excitations from a reduced sensor array could greatly improve current techniques in remote patient monitoring. Such an approach could allow continuous monitoring of clinically relevant biomechanical variables that are ideal for personalizing rehabilitation. In this paper, we introduce the notion of a muscle synergy function which describes the synergistic relationship between a subset of muscles. We develop from first principles an approximation to their behavior using Gaussian process regression and demonstrate the utility of the technique for estimating the excitation time-series of leg muscles during normal walking for nine healthy subjects. Specifically, excitations for six muscles were estimated using surface electromyography (sEMG) data during a finite time interval (called the input window) from four different muscles (called the input muscles) with mean absolute error (MAE) less than 5.0% of the maximum voluntary contraction (MVC) and that accounts for 82-88% of the variance (VAF) in the true excitations. Further, these estimated excitations informed muscle activations with less than 4.0% MAE and 89-93% VAF. We also present a detailed analysis of a number of different modeling choices, including every possible combination of four-, three- and two-muscle input sets, the size and structure of the input window, and the stationarity of the Gaussian process covariance functions. Further, application specific modifications for future use are discussed. The proposed technique lays a foundation to explore the use of reduced wearable sensor arrays and muscle synergy functions for monitoring clinically relevant biomechanics during daily life.

Falls are a significant problem for persons with multiple sclerosis (PwMS). Yet fall prevention interventions are not often prescribed until after a fall has been reported to a healthcare provider. While still nascent, objective fall risk assessments could help in prescribing preventative interventions. To this end, retrospective fall status classification commonly serves as an intermediate step in developing prospective fall risk assessments. Previous research has identified measures of gait biomechanics that differ between PwMS who have fallen and those who have not, but these biomechanical indices have not yet been leveraged to detect PwMS who have fallen. Moreover, they require the use of laboratory-based measurement technologies, which prevent clinical deployment. Here we demonstrate that a bidirectional long short-term (BiLSTM) memory deep neural network was able to identify PwMS who have recently fallen with good performance (AUC of 0.88) based on accelerometer data recorded from two wearable sensors during a one-minute walking task. These results provide substantial improvements over machine learning models trained on spatiotemporal gait parameters (21% improvement in AUC), statistical features from the wearable sensor data (16%), and patient-reported (19%) and neurologist-administered (24%) measures in this sample. The success and simplicity (two wearable sensors, only one-minute of walking) of this approach indicates the promise of inexpensive wearable sensors for capturing fall risk in PwMS.

Hawley, VS, Gurchiek, RD, and van Werkhoven, H. Can foot anthropometry predict vertical jump performance? J Strength Cond Res XX(X): 000-000, 2020-Vertical jumping is an important element of many sporting activities, and whether anthropometric adaptations can predict jumping performance is of interest. Few studies have specifically considered anthropometric measures of the foot and its link to performance. Furthermore, previous studies have mainly focused on a male subject pool, and whether relationships are consistent across sexes is unclear. The purpose of this study was to investigate relationships between common anthropometric measures, as well as specific foot measures, and jump performance in men and women. Anthropometric measures of 21 men (age: 22.0 ± 1.5 years; stature: 181.4 ± 6.3 cm; body mass: 85.6 ± 9.4 kg) and 21 women (age: 21.2 ± 1.8 years; stature: 166.1 ± 7.5 cm; body mass: 61.4 ± 11.4 kg) were taken before performing 3 maximal countermovement jumps (CMJs). Correlational analysis was used to determine relationships between anthropometric measures and CMJ height (a priori significance set at p≤ 0.05, effect size: small >0.1; medium >0.3; large >0.5). There was no significant correlation between anthropometric variables and CMJ height for men, whereas for women, mass (r = -0.585, p = 0.005, large effect), foot length (r = -0.533, p = 0.013, large effect), and toe length (r = -0.604, p = 0.004, large effect) showed significant negative correlations with CMJ height. The unexpected result that smaller feet and toes predicted higher jumps for women warrants further investigation. Furthermore, these results highlight the need to incorporate diverse subject pools, and a need for caution when generalizing across sexes.

Continuous observation of muscle activity could provide a comprehensive picture of the loads experienced by muscles and joints during daily life. However, a major limitation to the practical application of this approach is the need to have surface electromyography (sEMG) sensors on all involved muscles. In this work, we model the synergistic relationship between muscles as a Gaussian process enabling the inference of unmeasured muscle excitations using a subset of measured data. Specifically, we developed a model for a single subject which uses sEMG data from four leg muscles to estimate the muscle excitation time-series of six other leg muscles during level walking at a self-selected speed. The proposed technique was able to accurately estimate the held-out muscle excitation time-series of the six muscles with correlation coefficients ranging from 0.74 to 0.87 and with mean absolute error less than 3%.

The Society of Thoracic Surgeons guidelines recommend surgical ablation (SA) at the time of concomitant mitral operations, aortic valve replacement, coronary artery bypass grafting (CABG), and aortic valve replacement plus CABG for patients in atrial fibrillation (AF). The goal of this analysis was to assess the influence of SA on long-term survival.A retrospective analysis of 20,407 consecutive CABG or valve procedures from 2008 to 2015 among seven centers reporting to a prospectively maintained clinical registry was conducted. Patients undergoing operation with documented preoperative AF were included (n = 2,740). Patients receiving SA were compared with patients receiving no SA. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity and mortality.The frequency of SA was 23.1% (n = 634), and an increase was seen in the rate of SA over the study period (p0.001). Concomitant SA was performed in 16.2% of CABG, 30.6% of valve, and 24.3% of valve plus CABG procedures. A substantial improvement was found in unadjusted survival among patients undergoing SA (hazard ratio 0.54, 95% confidence interval: 0.42 to 0.70). Moreover, no differences were found in postoperative complications. SA did have longer bypass times (p0.001) but a shorter overall length of stay (p 0.001). After risk adjustment, SA patients had an improved 5-year survival (hazard ratio 0.69, 95% confidence interval: 0.51 to 0.92), and the effect was observed across all operations.In a multicenter cohort of patients with AF, concomitant SA resulted in substantially improved long-term survival across patients who underwent CABG, valve, and valve plus CABG. These findings support current guidelines from The Society of Thoracic Surgeons that recommend broader application of concomitant SA.

The assessment of sprint velocity is useful for evaluating performance and guiding training interventions. In this paper, we describe an adaptive filtering algorithm to estimate sprint velocity using a single, sacrum-worn magneto-inertial measurement unit. Estimated instantaneous velocity, average 10 m interval velocity, and peak velocity during 40 m sprints from the proposed method were compared to a reference method using photocell position-time data. Concurrent validity of the proposed method was assessed using mean absolute error and mean absolute percent error for all velocity estimates. The significance of the mean error was assessed using a factorial ANOVA for average interval velocity and a paired-samples t test for peak velocity. Reliability was assessed using Bland–Altman 95% limits of agreement for repeated measures. Average interval velocity was underestimated early in the sprint (− 0.25 to − 0.05 m/s) and overestimated later (0.13 m/s) with mean absolute error between 0.20 m/s (3.95%) and 0.62 m/s (7.78%). The average mean absolute error was 0.45 m/s (7.02%) for instantaneous velocity and 0.63 m/s (7.84%) for peak velocity. The limits of agreement grew progressively wider at greater distances (− 0.59 to 0.34 m/s for 0–10 m and − 1.32 to 1.59 m/s for 30–40 m). The estimation error from the proposed method is comparable to other wearable sensor-based methods and suggests its potential use to assess sprint performance.

Like many semi-arid regions, southern Alberta, Canada, has many large dams and reservoirs, most of which were constructed decades ago. These dams provide important socioeconomic benefits, but can a...

Storage reservoirs are an important part of the water infrastructure in both the USA and Canada. Their operations are important not only for water supply but also for downstream aquatic and riparian ecosystems. Public agencies operate some of the most important water supply reservoirs in both nations: the federal Bureau of Reclamation in the western USA and the provincial Alberta Environment and Parks in Canada’s South Saskatchewan River Basin. This paper examines legal and policy issues affecting potential changes in reservoir operations as an adaptation strategy in the western USA and southern Alberta and considers the two agencies’ policies and practices on reviewing dam operations. Although both agencies appear to recognize the potential value of reviewing and revising their reservoir operating plans, neither makes a practice of doing so. Thus, there is no program to review the operations of water supply projects; by contrast, hydropower project operations have been reviewed and revised in both nations. The two agencies have similar approaches even though federal laws and institutions are important for reservoir operations in the USA, but have little influence in Alberta. Whether federal or provincial, these agencies have operated their projects primarily to benefit local interests.

Background This study evaluates the influence of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting on postoperative morbidity and long-term survival among diabetic patients undergoing coronary artery bypass grafting (CABG). Methods A multicenter, retrospective analysis of 47,984 consecutive CABGs performed from 1992 to 2014 at 7 medical centers was conducted. Among the study population, 1,482 CABGs with BIMA were identified, and 1,297 BIMA patients were propensity-matched to 1,297 SIMA patients. The study cohort for this analysis, drawn from matched data, included 430 diabetic patients: 217 SIMA and 213 BIMA. The primary endpoint was long-term survival. Secondary endpoints included postoperative morbidity, length of stay, and in-hospital mortality. Results The median duration of follow-up was 9.3 (range, 4.3 to 13.9) years. Among propensity-matched diabetic patients, there was no significant difference in age, body mass index, or major baseline comorbidities. The groups were also well matched on the number of diseased coronary arteries and number of distal anastomoses performed. There was no difference in the rate of mediastinitis or sternal dehiscence ( p = 0.503) or in-hospital mortality ( p = 0.758) between groups. Both groups had a similar median length of stay of 5 (range, 4 to 7) days. Diabetic patients who received a BIMA had significantly improved long-term survival when compared with SIMA patients (hazard ratio 0.75 [95% confidence interval 0.57 to 0.98], p = 0.034). Conclusions Among diabetics undergoing CABG, use of BIMA grafting does not result in increased in-hospital morbidity or mortality and confers a long-term survival advantage when compared with SIMA grafting. Thus, diabetic patients should be considered for BIMA grafting more frequently.

Background: Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA. Methods: We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization. Results: The median duration of follow-up was 13.2 (IQR, 7.4–17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65–0.94]; P =0.009). Among the matched cohort, 19.4% (n=252) of patients receiving SIMA underwent repeat revascularization, whereas this frequency was 15.1% (n=196) among patients receiving BIMA ( P =0.004). The majority of repeat revascularization procedures were percutaneous coronary interventions (94.2%), and this did not differ between groups ( P =0.274). Groups also did not differ in the ratio of native versus graft vessel percutaneous coronary intervention ( P =0.899), or regarding percutaneous coronary intervention target vessels; the most common targets in both groups were the right coronary ( P =0.133) and circumflex arteries ( P =0.093). In comparison with SIMA, BIMA grafting was associated with a reduction in all-cause mortality at 12 years of follow-up (HR, 0.79 [95% CI, 0.69–0.91]; P =0.001), and there was no difference in in-hospital morbidity. Conclusions: BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting.

The purpose of this investigation was to determine the feasibility of using a single inertial measurement unit (IMU) placed on the sacrum to estimate 3-dimensional ground reaction force (F) during linear acceleration and change of direction tasks. Force plate measurements of F and estimates from the proposed IMU method were collected while subjects (n=15) performed a standing sprint start (SS) and a 45° change of direction task (COD). Error in the IMU estimate of step-averaged component and resultant F was quantified by comparison to estimates from the force plate using Bland-Altman 95% limits of agreement (LOA), root mean square error (RMSE), Pearson's product-moment correlation coefficient (r), and the effect size (ES) of the differences between the two systems. RMSE of the IMU estimate of step-average F ranged from 37.70 N to 77.05 N with ES between 0.04 and 0.47 for SS while for COD, RMSE was between 54.19 N to 182.92 N with ES between 0.08 and 1.69. Correlation coefficients between the IMU and force plate measurements were significant (p≤0.05) for all values (r=0.53 to 0.95) except the medio-lateral component of step-average F. The average angular error in the IMU estimate of the orientation of step-average F was ≤10° for all tasks. The results of this study suggest the proposed IMU method may be used to estimate sagittal plane components and magnitude of step-average F during a linear standing sprint start as well as the vertical component and magnitude of step-average F during a 45° change of direction task.

Presented here is the design of the Mechanical Ventilator Milano (MVM), a novel mechanical ventilator designed for rapid mass production in response to the COVID-19 pandemic to address the urgent shortage of intensive therapy ventilators in many countries, and the growing difficulty in procuring these devices through normal supply chains across borders. This ventilator is an electro-mechanical equivalent of the old and reliable Manley Ventilator, and is able to operate in both pressure-controlled and pressure-supported ventilation modes. MVM is optimized for the COVID-19 emergency, thanks to the collaboration with medical doctors in the front line. MVM is designed for large-scale production in a short amount of time and at a limited cost, as it relays on off-the-shelf components, readily available worldwide. Operation of the MVM requires only a source of compressed oxygen (or compressed medical air) and electrical power. Initial tests of a prototype device with a breathing simulator are also presented. Further tests and developments are underway. At this stage the MVM is not yet a certified medical device but certification is in progress.

Objectives Understanding the differences in baseball pitching biomechanics between American and Japanese pitchers may help with training and developing these athletes. The purpose of this study was to investigate the kinematic and kinetic differences in collegiate baseball pitchers from United States of American and Japan. Design Controlled laboratory study. Methods Data were analyzed for 11 American and 11 Japanese collegiate pitchers throwing fastballs using 3D motion capture (480 Hz). Results The Americans were heavier (95 ± 7 kg vs 81 ± 7 kg), taller (189 ± 3 cm vs 180 ± 6 cm), and had faster ball velocity (39 ± 1 m/s vs 35 ± 2 m/s). By the end of arm cocking phase, the American pitchers had rotated their shoulder to a greater degree (p = 0.021, d = 1.5) and at ball release the Japanese had greater knee flexion (p = 0.020, d = 1.2). American pitchers exhibited greater peak kinetics on the throwing arm; however, when normalized for height and weight only three differences remained. Conclusion The differences found between the American and Japanese players could contribute to the increased ball velocity in the American pitchers. Additionally, throwing arm peak kinetics were greater in the American pitchers which may help generate greater ball velocity; however, increased kinetics may also lead to increased risk of injury.

Walking impairments are highly prevalent in persons with multiple sclerosis (PwMS) and are associated with reduced quality of life. Walking is traditionally quantified with various measures, including patient self-reports, clinical rating scales, performance measures, and advanced lab-based movement analysis techniques. Yet, the majority of these measures do not fully characterize walking (i.e., gait quality) nor adequately reflect walking in the real world (i.e., community ambulation) and have limited timescale (only measure walking at a single point in time). We discuss the potential of wearable sensors to provide sensitive, objective, and easy-to-use assessment of community ambulation in PwMS. Wearable technology has the ability to measure all aspects of gait in PwMS yet is under-studied in comparison with other populations (e.g., older adults). Within the studies focusing on PwMS, half that measure pace collected free-living data, while only one study explored gait variability in free-living conditions. No studies explore gait asymmetry or complexity in free-living conditions. Wearable technology has the ability to provide objective, comprehensive, and sensitive measures of gait in PwMS. Future research should investigate this technology’s ability to accurately assess free-living measures of gait quality, specifically gait asymmetry and complexity.

Introduction: The human adult heart contains a subset of mesenchymal cells characterized by high proliferative potential and capability to differentiate into different cell types. We recently demonstrated that a high level of ErbB2 expression is associated with differentiation of human highly proliferative cells (hHiPC) into endothelial cells in vitro. Based on our findings, we hypothesized that ErbB2 high hHiPC play a critical role in early revascularization and repair of injured heart. To test this hypothesis, we performed xenotransplantation of human ERBB2 high hHiPC into mouse hearts and analyzed the phenotype of transplanted cells and cardiac function on day 7 after experimental myocardial infarction (MI). Methods: The effect of ErbB2 high hHiPC was tested in immunodeficient NSG mice. MI was induced by permanent ligation of the left coronary artery. Human ERBB2 high hHiPC (2.5 x 10 5 cells) were injected into the peri-infarct zone immediately after MI. Echocardiography was performed on unsedated mice before and on days 7 after MI. Examination of transplantation efficiency and hHiPC phenotype was performed using flow cytometric analysis of cell suspension obtained from left ventricles (LV). Results: We found that up to 25% of cardiac endothelial cells were represented by cells that originated from hHiPC, as identified by specific expression of human CD31, in mouse LV, on day 7 after MI. The total number of cells expressing mouse or human endothelial cell markers, CD31 and CD105, within non-immune cardiac cell population was higher in mice that received injection of hHiPC compared to control mice (PBS injection) (4.7 vs. 2.9 x 10 5 cells, hHiPC vs. PBS, p= 0.026 ). Echocardiographic analysis revealed that mice which received an injection of ERBB2 high cells demonstrated significantly improved cardiac function compared to control mice injected with PBS (fractional shortening: 21.6% vs. 15.3% for hHiPC vs. PBS, p=0.023 ). Conclusion: ERBB2 high hHiPC survive, undergo endothelial cell differentiation in vivo, and contribute to the pool of cardiac endothelial cells after experimental myocardial infarction. A population of ErbB2 high hHiPC obtained from adult human hearts can be used to improve the revascularization of injured myocardium or other tissues.

This paper presents an automated, wearable sensor-based remote gait analysis method and demonstrates its utility by evaluating gait in patients recovering from anterior cruciate ligament (ACL) reconstruction. Patients wore a single wearable sensor over the rectus femoris of each leg to collect over 15 hours of 3-axis accelerometer and surface electromyography data during daily life. A support vector machine classifier was used to identify four second windows of walking activity. Across all subjects 10,451 strides were extracted from these windows and categorized as occurring during either fast or slow walking. Muscle activation and 3-axis thigh acceleration time-series for each stride were resampled as a percentage of stride cycle and ensemble curves from both legs were compared using correlation as an index of gait pattern symmetry. Our results suggest the proposed method successfully identifies time-series gait asymmetries between affected and unaffected legs when comparing patients early post-surgery ( $ weeks) and later ( $> \pmb {14}$ weeks) in recovery for each walking speed. These results point toward future use of this approach as a digital biomarker for rehabilitation progress in this population.

Childhood anxiety and depression often go undiagnosed. If left untreated these conditions, collectively known as internalizing disorders, are associated with long-term negative outcomes including substance abuse and increased risk for suicide. This paper presents a new approach for identifying young children with internalizing disorders using a 3-min speech task. We show that machine learning analysis of audio data from the task can be used to identify children with an internalizing disorder with 80% accuracy (54% sensitivity, 93% specificity). The speech features most discriminative of internalizing disorder are analyzed in detail, showing that affected children exhibit especially low-pitch voices, with repeatable speech inflections and content, and high-pitched response to surprising stimuli relative to controls. This new tool is shown to outperform clinical thresholds on parent-reported child symptoms, which identify children with an internalizing disorder with lower accuracy (67–77% versus 80%), and similar specificity (85–100% versus 93%), and sensitivity (0–58% versus 54%) in this sample. These results point toward the future use of this approach for screening children for internalizing disorders so that interventions can be deployed when they have the highest chance for long-term success.

Estimation of ground reaction forces in runners has been limited to laboratory environments by means of instrumented treadmills, in-ground force plates and optoelectronic systems. Recent advances in estimation techniques using wearable sensors for kinematic analysis and sports performance could enable estimation outside the laboratory. This paper proposes a state-input-parameter estimation framework to continuously estimate the vertical ground reaction force waveform during running. By modeling a runner as a single degree of freedom mass-spring-damper with acceleration measurements at the sacrum a state-space formulation can be applied using Newtonian methods. A dual-Kalman filter is employed to estimate the unmeasured system input which feeds through to an unscented Kalman filter to estimate system dynamics and unknown model parameters (e.g. spring stiffness). For validation, 14 subjects performed three one-minute running trials at three different speeds (self-selected slow, comfortable, and fast) on a pressure-sensor-instrumented treadmill. The estimated vertical ground reaction force waveform parameters; peak vertical ground reaction force (RMSE=6.1-7.2%,ρ=0.95-0.97), vertical impulse (RMSE=8.5-13.0%,ρ=0.50-0.60), loading rate (RMSE=24.6-39.4%,ρ=0.85-0.93), and cadence RMSE

Federal dams have been the focus of major disputes involving application of the Endangered Species Act, especially Section 7 and its prohibition on federal actions causing jeopardy to protected species. Operating agencies and project beneficiaries have sought to keep the ESA from restricting dam operations, including by arguing that such operations are nondiscretionary and thus exempt from Section 7. In proposing new ESA implementing rules, the Trump Administration suggested – though did not formally propose – that ongoing federal actions (such as dam operations) should be considered part of the “environmental baseline” for Section 7 purposes. Redefining the environmental baseline in that way could have dramatically changed over 25 years of practice in applying the ESA to federal dams, reducing or even eliminating the crucial protection provided by Section 7. Although the Administration ultimately adopted a more modest change to the definition, it apparently did so due to legal rather than policy concerns. The article then examines the policy goals that the Administration apparently sought to pursue with the suggested rule, and identifies issues that will likely arise from ongoing efforts to pursue those policy goals at the project level. Although the Administration decided against a national rollback regarding ongoing actions, there are sure to be ongoing battles over the application of the ESA to federal dams.

Introduction: Dysregulation of endothelial nitric oxide synthase (eNOS) and generation of nitric oxide (NO) are critical early indicators for diabetes-induced endothelial dysfunction and cardiovascular complications. We hypothesize that levels of NO production and eNOS expression by endothelial cells are decreased in DM subjects when compared to non-DM subjects. Methods: The study cohort consisted of 9 non-DM subjects and 6 DM subjects undergoing myocardial biopsy at the time of coronary artery bypass grafting surgery. The non-myocyte cell suspensions from the left ventricle (LV), right atrial appendages (RAA), and skeletal muscle (SKM) tissue were analyzed by flow cytometry to measure production of nitric oxide in subpopulations of endothelial and non-endothelial cells. Cells in suspension were incubated with DAF-2DA in the presence or absence of NO synthase inhibitor, L-NAME. Flow cytometry was used to determine production of NO in subpopulations of endothelial and non-endothelial cells from biopsies. Measurements of eNOS and phospho-eNOS (ser1177) were performed using western blot. Results: Basal Nitric oxide production was measurable in non-diabetic subjects \ in 55%, 80% and 65% of unstimulated endothelial cells obtained from RAA, LV and SKM biopsies, compared to 40%, 40%, and 66%, respectively in diabetic subjects ( P < 0.02, DM vs Non-DM). No differences were found in the number of NO-producing non-endothelial cells between DM and non-DM subjects. The level of eNOS showed a trend towards decreased protein expression in DM subjects compared to non-DM. Conclusions: Generation of NO by endothelial cells and level of eNOS expression are decreased in left ventricular endothelial cells of DM patients compared to non-DM. Left ventricular biopsies can be used safely for assessment of NO dysregulation and endothelial dysfunction, and whether these can be improved with interventions targeting diabetic cardiovascular disease.

Rice, PE, Gurchiek, RD, and McBride, JM. Physiological and biomechanical responses to an acute bout of high kicking in dancers. J Strength Cond Res 32(10): 2954-2961, 2018-High-kick precision competitive dance involves the integration of kicking inline, jumping, and turning during a 3-minute routine and causes a disturbance to both aerobic and anaerobic systems. However, no known study has quantified the effect of a hick-kick-specific protocol on blood lactate (BL), heart rate (HR), and countermovement jump (CMJ) performance. A group of adolescent high-kick dancers (n = 20; age = 15.0 ± 1.8 years; height = 161.5 ± 8.2 cm; body mass = 56.3 ± 11.0 kg; and dance team/weight lifting experience = 2.1 ± 0.9 years) participated in this investigation. Participants' BL was collected, and 3 CMJ trials were performed before (PRE) and after (POST) completing the high-kick protocol. The high-kick protocol consisted of intermittent running and kicking in place for a total of 1:45 at a tempo of 160 b·min, while average and peak HR (HRavg; HRpeak) were recorded. Jump height (JH), maximal trunk flexion (MTF), take-off angle (TOA), and relative peak power (PP) were determined from PRE and POST CMJ trials. During kicking, HRavg and HRpeak (n = 13) were 172.4 ± 15.7 b·min and 207.0 ± 23.0 b·min, respectively. Dancers' (n = 20) BL significantly (p ≤ 0.05) increased from 1.5 ± 0.5 to 8.6 ± 1.5 mmol·L, and JH and PP significantly decreased from 0.42 ± 0.08 to 0.36 ± 0.04 m and 41.3 ± 5.5 to 38.5 ± 4.0 W·kg, respectively, from PRE to POST. No significant changes occurred in MTF and TOA measurements from PRE to POST. The demands introduced during a high-kick-specific protocol can therefore be recognized as a metabolic and mechanical stimulus for fatigue; however, esthetics seem to be unaffected. Such findings may indicate that this modality of dance necessitates supplemental strength and conditioning training similar to other sports to sustain the loads of high-kick dance.

Background A patient’s hemoglobin (Hb) A1c level, regardless of diabetic status, is a measure of glycemic control. Studies have found it is an independent predictor of short-term death in patients undergoing coronary artery bypass grafting (CABG). In this study, we used preoperative HbA1c to assess whether levels are associated with short-term and long-term survival after CABG. Methods From a regional registry of consecutive cases, we identified 6,415 patients undergoing on-pump isolated CABG from 2008 to 2015 with documented preoperative HbA1c level. We defined four HbA1c groups: less than 5.7% (n = 1,713), 5.7% to 6.4% (n = 2,505), 6.5% to 8.0% (n = 1,377), and more than 8% (n = 820). Relationship to in-hospital outcomes and long-term survival was assessed. Outcome rates and hazard ratios were adjusted for patient and disease risk factors using multivariable logistic regression and Cox models. Results The study included 3,740 patients (58%) not diagnosed as having diabetes and 2,674 with diabetes. Prediabetes (HbA1c 5.7% to 6.4%) was documented in 52% (n = 1,933) of nondiabetic patients. Higher HbA1c values were associated with younger age, female sex, greater body mass index, more comorbid diseases, lower ejection fraction, more 3-vessel coronary disease, and recent myocardial infarction (p Conclusions Preadmission glycemic control, as assessed by HbA1c, is predictive of long-term survival, with higher levels associated with poorer prognosis. Whether this risk can be modified by better glycemic control postoperatively remains to be determined.

Interstate rivers are subject to the doctrine of equitable apportionment, whereby the Supreme Court seeks to ensure that all states that share such rivers get a fair portion of their benefits. The Court has rarely issued an equitable apportionment decree, however, and there is little law on whether the doctrine protects river flows for environmental purposes. The ongoing Florida v. Georgia litigation in the Supreme Court raises this issue, as Florida seeks to limit consumptive uses by upstream Georgia to preserve flows in the Apalachicola River, which provide both economic and environmental benefits. This article summarizes both the equitable apportionment doctrine and the concept of environmental flows, then considers prior Supreme Court cases dealing with environmental issues on interstate rivers. It then examines Florida v. Georgia, including the Court’s 2018 decision where it narrowly allowed the litigation to continue. A key issue in that decision was the role of the Army Corps of Engineers, which operates several federal dams in the river basin at issue in the case. This article examines the views of the Court on the role of the Corps and its dam operations, and contends that the Court focused too narrowly on the agency’s existing plan while overlooking the broader legal and policy context. It concludes with some brief thoughts on the future of the Florida v. Georgia litigation and environmental flows.

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Genetic engineering technology has become sophisticated enough to allow precise manipulation of bacterial genetic material. Engineering efforts with these technologies have created modified bacteria for various medical, industrial, and environmental purposes, but organisms designed for specific functions require improvements in stability, longevity, or efficiency of function. Most bacteria live in multispecies communities, whose composition may be closely linked to the effect the community has on the environment. Bacterial engineering efforts will benefit from building communities with regulated compositions, which will enable more stable and powerful community functions.We present a design of a synthetic two member bacterial community capable of maintaining its composition at a defined ratio of [cell type 1]: [cell type 2]. We have constructed the genetic motif that will act in each cell in the two member community, containing an AHL-based negative feedback loop that activates ccdB toxin, which caps population density with increasing feedback strength. It also contains one of two ccdB sequestration modules, either the ccdA protein antitoxin, or an RNA device which prevents transcription and translation of ccdB mRNA, that rescues capped population density with induction. We compare absorbance and colony counting methods of estimating bacterial population density, finding that absorbance-based methods overestimate viable population density when ccdB toxin is used to control population density.Prior modeling results show that two cell types containing this genetic circuit motif that reciprocally activate the other’s ccdB sequestration device will establish a steady state ratio of cell types. Experimental testing and tuning the full two member community will help us improve our modeling of multi-member bacterial communities, learn more about the strengths and weaknesses of our design for community composition control, and identify general principles of design of compositionally-regulated microbial communities.

Dance involves a high volume of aesthetic, stretch-shortening cycle (SSC) actions, which may cause unique adaptations to performance. The strength dancers possess to withstand such frequency of SSCs remains elusive. The extensive training that dancers experience from a young age, however, yields anatomical and strength development that may contrast with that of untrained individuals. Therefore, the purpose of this study was to investigate differences in musculo-articular stiffness and maximal isometric plantar flexion and knee extension force between dancers and untrained individuals. A total of 16 females volunteered to participate in the study (N = 8 dancers; N = 8 untrained individuals). Dancers had a minimum of 10 years of dance experience and were currently training at the collegiate dance level three or more times per week. Untrained individuals had no dance background, nor were they currently involved in any form of regularized physical activity. All subjects completed a series of lower leg measurements and strength tests. This included a musculo-articular stiffness measurement using a free-oscillation technique, along with maximal isometric plantar flexion (MIP) and maximal isometric knee extension (MIKE) testing. The data indicate that dancers had a significantly greater rate of force development and peak force during MIP and rate of force development during MIKE in comparison to untrained individuals. Dancers also possessed significantly greater musculo-articular stiffness. Hence, the data provide some evidence that involvement in dance can result in greater muscle force generating capacity and musculo-articular stiffness due to the SSC mechanisms involved in dance movements.

The adult human heart contains a subpopulation of highly proliferative cells. The role of ErbB receptors in these cells has not been studied. From human left ventricular (LV) epicardial biopsies, we isolated highly proliferative cells (eHiPC) to characterize the cell surface expression and function of ErbB receptors in the regulation of cell proliferation and phenotype. We found that human LV eHiPC express all four ErbB receptor subtypes. However, the expression of ErbB receptors varied widely among eHiPC isolated from different subjects. eHiPC with higher cell surface expression of ErbB2 reproduced the phenotype of endothelial cells and were characterized by endothelial cell-like functional properties. We also found that EGF/ErbB1 induces VEGFR2 expression, while ligands for both ErbB1 and ErbB3/4 induce expression of Tie2. The number of CD31posCD45neg endothelial cells is higher in LV biopsies from subjects with high ErbB2 (ErbB2high) eHiPC compared to low ErbB2 (ErbB2low) eHiPC. These findings have important implications for potential strategies to increase the efficacy of cell-based revascularization of the injured heart, through promotion of an endothelial phenotype in cardiac highly proliferative cells.

Arterial conduits are preferred to venous conduits for coronary artery bypass grafting because of longer patency. A single internal mammary artery (SIMA) is used routinely. Bilateral internal mammary arteries (BIMA) are used less frequently. We sought to determine whether BIMA were superior to SIMA.From our regional registry of consecutive open heart operations, we identified 47,984 patients who underwent isolated coronary artery bypass grafting from 1992 to 2014. Of the 1,482 BIMA patients, 1,297 were propensity matched to a cohort of SIMA patients. Short-term outcomes were compared using standard statistical techniques. Long-term survival was compared using Kaplan-Meier estimators and compared using a log-rank test.BIMA patients were younger and had fewer comorbid conditions than SIMA patients. After propensity weighting, BIMA and SIMA patients were well matched. There was no difference in in-hospital outcomes for BIMA versus SIMA patients for mortality (1.2% [n = 15] vs 0.8% [n = 10], p = 0.315), stroke (0.7% [n = 9] vs 0.7% [n = 9), p = 1.000), bleeding (2.2% [n = 28] vs 2.8% [n = 36], p = 0.311), or mediastinitis (0.8% [n = 10] vs 0.9% [n = 12], p = 0.667). The median follow-up was 12 years. Survival was better for BIMA than SIMA (adjusted hazard ratio, 0.79; 95% confidence interval, 0.69 to 0.91; p0.001). Survival curves began to separate after 5 years. At 15 years, the absolute difference in survival was 8.4%.In a large regional experience, BIMA is associated with no upfront risk of adverse events and improved long-term survival compared with SIMA. Our results indicate that BIMA conduits should be considered more frequently during coronary artery bypass grafting due to their demonstrated survival advantage.

Wearable sensors have the potential to enable comprehensive patient characterization and optimized clinical intervention. Critical to realizing this vision is accurate estimation of biomechanical time-series in daily-life, including joint, segment, and muscle kinetics and kinematics, from wearable sensor data. The use of physical models for estimation of these quantities often requires many wearable devices making practical implementation more difficult. However, regression techniques may provide a viable alternative by allowing the use of a reduced number of sensors for estimating biomechanical time-series. Herein, we review 46 articles that used regression algorithms to estimate joint, segment, and muscle kinematics and kinetics. We present a high-level comparison of the many different techniques identified and discuss the implications of our findings concerning practical implementation and further improving estimation accuracy. In particular, we found that several studies report the incorporation of domain knowledge often yielded superior performance. Further, most models were trained on small datasets in which case nonparametric regression often performed best. No models were open-sourced, and most were subject-specific and not validated on impaired populations. Future research should focus on developing open-source algorithms using complementary physics-based and machine learning techniques that are validated in clinically impaired populations. This approach may further improve estimation performance and reduce barriers to clinical adoption.

Wearable sensor-based algorithms for estimating joint angles have seen great improvements in recent years. While the knee joint has garnered most of the attention in this area, algorithms for estimating hip joint angles are less available. Herein, we propose and validate a novel algorithm for this purpose with innovations in sensor-to-sensor orientation and sensor-to-segment alignment. The proposed approach is robust to sensor placement and does not require specific calibration motions. The accuracy of the proposed approach is established relative to optical motion capture and compared to existing methods for estimating relative orientation, hip joint angles, and range of motion (ROM) during a task designed to exercise the full hip range of motion (ROM) and fast walking using root mean square error (RMSE) and regression analysis. The RMSE of the proposed approach was less than that for existing methods when estimating sensor orientation ( 12 . 32 ∘ and 11 . 82 ∘ vs. 24 . 61 ∘ and 23 . 76 ∘ ) and flexion/extension joint angles ( 7 . 88 ∘ and 8 . 62 ∘ vs. 14 . 14 ∘ and 15 . 64 ∘ ). Also, ROM estimation error was less than 2 . 2 ∘ during the walking trial using the proposed method. These results suggest the proposed approach presents an improvement to existing methods and provides a promising technique for remote monitoring of hip joint angles.

This special issue focuses on a range of topics relating to Great Lakes water and the environment, including the Great Lakes-St. Lawrence River Basin Water Resources Compact (Great Lakes Compact). This interstate agreement, approved by Congress in 2008,2 represents one of the more important recent developments in water policy, not just in the Great Lakes, but nationally as well.3 There are many interstate water compacts, primarily in the western United States,4 but the Great Lakes Compact is unique. From a western perspective, what makes this new compact so unusual is that it actually restricts diversions for consumptive uses for purposes of protecting the Great Lakes environment. The western compacts essentially take the opposite approach, emphasizing old-school water development and use, while mostly ignoring environmental matters. 6 In practice, the water development favored by these compacts-chiefly in the form of large federal water projects-sharply altered western river ecosystems, resulting in serious environmental problems. These problems have not prompted changes in the compacts (or Supreme Court decrees) that formally allocate interstate waters among the western states. But largely because of the

Heavy load carriage has been identified as a main contributing factor to the high incidence of overuse injuries in soldiers. Peak vertical ground reaction force (VGRFMAX) and maximal vertical loading rates (VLRMAX) may increase during heavy prolonged load carriage with the development of muscular fatigue and reduced shock attenuation capabilities. The objectives of the current study were (1) to examine physiological and biomechanical changes that occur during a prolonged heavy load carriage task, and (2) to examine if this task induces neuromuscular fatigue and changes in muscle architecture. Eight inexperienced female participants walked on an instrumented treadmill carrying operational loads for 60 minutes at 5.4 km·h–1. Oxygen consumption (), heart rate, rating of perceived exertion (RPE), trunk lean angle, and ground reaction forces were recorded continuously during task. Maximal force and in-vivo muscle architecture were assessed pre- and posttask. Significant increases were observed for VGRFMAX, VLRMAX, trunk lean angle, , heart rate, and RPE during the task. Increased vastus lateralis fascicle length and decreased maximal force production were also observed posttask. Prolonged heavy load carriage, in an inexperienced population carrying operational loads, results in progressive increases in ground reaction force parameters that have been associated with overuse injury.