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ObjectiveHigh levels of psychological distress increase the risk of a wide range of medical diseases. In this study, we investigated the association between posttraumatic stress disorder (PTSD) and kidney disease.MethodsWorld Trade Center (WTC) responders were included if they had two or more measures of estimated glomerular filtration rate (eGFR). The PTSD Checklist (PCL) was used to define no PTSD (PCL < 40), "mild" PTSD (40 ≤ PCL

BACKGROUND: Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans. METHODS: Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts. RESULTS: BPD, X(2)=11.1, p

Objective: Catheter placement for thoracic epidural analgesia (TEA) is technically challenging; however, methods for teaching this technique to anesthesia residents have not been well-studied. The present study aimed to determine optimal teaching methods for proficient TEA catheter placement by comparing video-based formal resident education with traditional bedside training by attending physicians. Design: Prospective, randomized study. Setting: Large academic hospital, single institution. Participants: The study comprised 76 postgraduate year 3 and 4 anesthesiology residents (38 intervention, 38 control). Interventions: Formal education included an instructional video on proper TEA technique. Measurements and Main Results: Measures of proficiency in TEA catheter placement included the time needed to complete the procedure successfully and the success of placement as indicated by patient confirmation. Residents who received formal video instruction had similar success in catheter placement and similar procedure times compared with the traditionally trained residents. The overall success rate was 99.2%, with faculty intervention required in only 17% of cases. More experienced residents (ie, having placed more epidural catheters) were faster at TEA catheter placement. Conclusions: Formal video education for TEA catheter placement provided no additional improvement of resident proficiency compared with traditional training at a high-volume academic center. The success rate was very high in this group of residents; however, experiences at other institutions may vary. Future studies are needed to determine optimum teaching strategies for TEA.

OBJECTIVE: Previous studies of military veterans have produced mixed findings regarding whether combat exposure is directly related to suicidal ideation or is indirectly related to suicidal ideation via its influence on other factors. The present study used a longitudinal design to test the hypothesis that posttraumatic stress disorder (PTSD) symptom severity mediates the effect of combat exposure on suicidal ideation in veterans METHOD: Participants included 319 post-9/11 Veterans (83.4% male; 42.1% White/52.1% Black; M(age) = 39.7) assessed at baseline, 6 months, and 12 months. Structural equation modeling and bootstrapped confidence intervals were employed to examine the direct and indirect relationships between combat exposure, suicidal ideation, and PTSD symptom severity. RESULTS: Results from the mediation model, in which demographic variables and non-combat trauma were included as covariates, revealed that the indirect effect of combat exposure on suicidal ideation via PTSD symptom severity was statistically significant, accounting for 64.1% of the covariance between combat exposure and suicidal ideation. CONCLUSIONS: This study provides longitudinal evidence that the effects of combat exposure on suicidal ideation are mediated by PTSD symptom severity, suggesting the importance of targeting such symptoms in treatment to mitigate suicide risk among veterans with combat exposure.

Rationale: Unstable ventilatory control (high loop gain) is a causal factor in the development of obstructive sleep apnea. Methods for quantifying loop gain using polysomnography have been develope...

In addition to question prompts for information transfer, we also used prompts to facilitate the expression of emotions. Our aim was to investigate how a question prompt list (QPL) is accepted by patients and whether it enhances interactional empowerment of the patients in the consultation with the radio-oncological treatment team before the beginning of radiotherapy. Adult cancer patients before the beginning of radiotherapy were randomly assigned to the intervention group (IG) or control group (CG). The patients in the IG received a QPL with predefined subsets and subject areas. After the physician’s consultation, both groups completed a self-developed, content validated questionnaire on interactional empowerment. The IG evaluated the QPL using a self-developed instrument. A total of 279 adult cancer patients participated in the study (IG n = 139/CG n = 140). The participants of the IG reported a significantly higher interactional empowerment compared with those of the CG (t(277) = − 2.71, p = .007, 95% CI [− 1.61, − 0.26], d = 0.29). 60.4% of the IG agreed “rather” or “very” that they used the QPL in consultation with the medical team. The QPL used in the consultation improved the self-assessed competence for interaction with the medical team and strengthened the interactional empowerment. The QPL was well accepted by the patients and is to be introduced into a routine as a practicable and simple instrument in the future. The support of patients in addressing concerns and fears is an important innovation.

This essay investigates how Juan de Segovia (d. 1458) used the Qur’ān in his engagement with Islam. The essay has three principal aims. First, it identifies certain distinctive aspects of Segovia’s use of the Qur’ān. Second, it examines his treatment of sacraments and soteriology in the Qur’ān. Third, it considers Segovia’s use of the Qur’ān in light of David Bertaina’s recent analysis of Christians and the Qur’ān. It is argued that, just as Segovia read the Qur’ān in various ways, he also used or cited the Qur’ān in various ways, for various ends and even for various audiences.

Purpose Increased use of Linac‐based stereotactic radiosurgery (SRS), which requires highly noncoplanar gantry trajectories, necessitates the development of efficient and accurate methods of collision detection during the treatment planning process. This work outlines the development and clinical implementation of a patient‐specific computed tomography (CT) contour‐based solution that utilizes Eclipse Scripting to ensure maximum integration with clinical workflow. Methods The collision detection application uses triangle mesh structures of the gantry and couch, in addition to the body contour of the patient taken during CT simulation, to virtually simulate patient treatments. Collision detection is performed using Binary Tree Hierarchy detection methods. Algorithm accuracy was first validated for simple cuboidal geometry using a calibration phantom and then extended to an anthropomorphic phantom simulation by comparing the measured minimum distance between structures to the predicted minimum distance for all allowable orientations. The collision space was tested at couch angles every 15° from 90 to 270 with the gantry incremented by 5° through the maximum trajectory. Receiver operating characteristic curve analysis was used to assess algorithm sensitivity and accuracy for predicting collision events. Following extensive validation, the application was implemented clinically for all SRS patients. Results The application was able to predict minimum distances between structures to within 3 cm. A safety margin of 1.5 cm was sufficient to achieve 100% sensitivity for all test cases. Accuracy obtained was 94.2% with the 5 cm clinical safety margin with 100% true positive collision detection. A total of 88 noncoplanar SRS patients have been currently tested using the application with one collision detected and no undetected collisions occurring. The average time for collision testing per patient was 2 min 58 s. Conclusions A collision detection application utilizing patient CT contours was developed and successfully clinically implemented. This application allows collisions to be detected early during the planning process, avoiding patient delays and unnecessary resource utilization if detected during delivery.

Regional networks of Global Navigation Satellite System (GNSS) stations cover seismically and volcanically active areas throughout the United States. Data from these networks have been used to produce high-precision, three-component velocity fields covering broad geographic regions as well as position time series that track time-varying crustal deformation. This information has contributed to assessing interseismic strain accumulation and related seismic hazard, revealed previously unknown occurrences of aseismic fault slip, constrained coseismic slip estimates, and enabled monitoring of volcanic unrest and postseismic deformation. In addition, real-time GNSS data are now widely available. Such observations proved invaluable for tracking the rapidly evolving eruption of Kīlauea in 2018. Real-time earthquake source modeling using GNSS data is being incorporated into tsunami warning systems, and a vigorous research effort is focused on quantifying the contribution that real-time GNSS can make to improve earthquake early warnings as part of the Advanced National Seismic System ShakeAlert system. Real-time GNSS data can also aid in the tracking of ionospheric disturbances and precipitable water vapor for weather forecasting. Although regional GNSS and seismic networks generally have been established independently, their spatial footprints often overlap, and in some cases the same institution operates both types of networks. Further integration of GNSS and seismic networks would promote joint use of the two data types to better characterize earthquake sources and ground motion as well as offer opportunities for more efficient network operations. Looking ahead, upgrading network stations to leverage new GNSS technology could enable more precise positioning and robust real-time operations. New computational approaches such as machine learning have the potential to enable full utilization of the large amounts of data generated by continuous GNSS networks. Development of seafloor Global Positioning System-acoustic networks would provide unique information for fundamental and applied research on subduction zone seismic hazard and, potentially, monitoring.

The golf swing has been associated with mechanical injury risk factors at many joints. One swing, the Minimalist Golf Swing, was hypothesised to reduce lumbar spine, lead hip, and lead knee ranges of motion and peak net joint moments, while affecting swing performance, compared to golfers' existing swings. Existing and MGS swings of 15 golfers with handicaps ranging from +2 to -20 were compared. During MGS downswing, golfers had 18.3% less lumbar spine transverse plane ROM, 40.7 and 41.8% less lead hip sagittal and frontal plane ROM, and 39.2% less lead knee sagittal plane ROM. MGS reduced lead hip extensor, abductor, and internal rotator moments by 17.8, 19.7 and 43%, while lead knee extensor, abductor, adductor and external rotator moments were reduced by 24.1, 26.6, 37 and 68.8% respectively. With MGS, club approach was 2° shallower, path 4° more in-to-out and speed 2 m/s slower. MGS reduced certain joint ROM and moments that are linked to injury risk factors, while influencing club impact factors with varying effect. Most golf injuries are from overuse, so reduced loads per cycle with MGS may extend the healthy life of joints, and permit golfers to play injury-free for more years.

Studies have reported that the age-adjusted incidence of cognitive impairment and dementia may have decreased over the past two decades. Aging is the predominant risk factor for Alzheimer’s disease and related dementias and for neurocognitive decline. However, aging cannot explain changes in overall age-adjusted incidence of dementia. The objective of this position paper was to describe the potential for cohort and period effects in cognitive decline and incidence of dementia. Cohort effects have long been reported in demographic literature, but starting in the early 1980s, researchers began reporting cohort trends in cognitive function. At the same time, period effects have emerged in economic factors and stressors in early and midlife that may result in reduced cognitive dysfunction. Recognizing that aging individuals today were once children and adolescents, and that research has clearly noted that childhood cognitive performance is a primary determinant of old-age cognitive performance, this is the first study that proposes the need to connect known cohort effects in childhood cognition with differences in late-life functioning.

Study Objectives The presence of flow limitation during sleep is associated with adverse health consequences independent of obstructive sleep apnea (OSA) severity (apnea-hypopnea index, AHI), but remains extremely challenging to quantify. Here we present a unique library and an accompanying automated method that we apply to investigate flow limitation during sleep. Methods A library of 117,871 breaths (N = 40 participants) were visually classified (certain flow limitation, possible flow limitation, normal) using airflow shape and physiological signals (ventilatory drive per intra-esophageal diaphragm EMG). An ordinal regression model was developed to quantify flow limitation certainty using flow-shape features (e.g. flattening, scooping); breath-by-breath agreement (Cohen’s ƙ); and overnight flow limitation frequency (R2, %breaths in certain or possible categories during sleep) were compared against visual scoring. Subsequent application examined flow limitation frequency during arousals and stable breathing, and associations with ventilatory drive. Results The model (23 features) assessed flow limitation with good agreement (breath-by-breath ƙ = 0.572, p < 0.001) and minimal error (overnight flow limitation frequency R2 = 0.86, error = 7.2%). Flow limitation frequency was largely independent of AHI (R2 = 0.16) and varied widely within individuals with OSA (74[32–95]%breaths, mean[range], AHI > 15/h, N = 22). Flow limitation was unexpectedly frequent but variable during arousals (40[5–85]%breaths) and stable breathing (58[12–91]%breaths), and was associated with elevated ventilatory drive (R2 = 0.26–0.29; R2 < 0.01 AHI v. drive). Conclusions Our method enables quantification of flow limitation frequency, a key aspect of obstructive sleep-disordered breathing that is independent of the AHI and often unavailable. Flow limitation frequency varies widely between individuals, is prevalent during arousals and stable breathing, and reveals elevated ventilatory drive. Clinical trial registration: The current observational physiology study does not qualify as a clinical trial.

Little is known about the characteristics and causes of early-onset cognitive impairment. Responders to the 2001 New York World Trade Center disaster represent an ageing population that was recently shown to have an excess prevalence of cognitive impairment. Neuroimaging and molecular data demonstrate that a subgroup of affected responders may have a unique form of parietal-dominant Alzheimer’s Disease. Recent neuropsychological testing and artificial intelligence approaches have emerged as methods that can be used to identify and monitor subtypes of cognitive impairment. We utilized data from World Trade Center responders participating in a health monitoring program and applied a deep learning approach to evaluate neuropsychological and neuroimaging data to generate a cortical atrophy risk score. We examined risk factors associated with the prevalence and incidence of high risk for brain atrophy in responders who are now at midlife. Training was conducted in a randomly selected two-thirds sample (N = 99) enrolled using of the results of a structural neuroimaging study. Testing accuracy was estimated for each training cycle in the remaining third subsample. After training was completed, the scoring methodology that was generated was applied to longitudinal data from 1441 World Trade Center responders. The artificial neural network provided accurate classifications of these responders in both the testing (Area Under the Receiver Operating Curve, 0.91) and validation samples (Area Under the Receiver Operating Curve, 0.87). At baseline and follow-up, responders identified as having a high risk of atrophy (n = 378) showed poorer cognitive functioning, most notably in domains that included memory, throughput, and variability as compared to their counterparts at low risk for atrophy (n = 1063). Factors associated with atrophy risk included older age [adjusted hazard ratio, 1.045 (95% confidence interval = 1.027–1.065)], increased duration of exposure at the WTC site [adjusted hazard ratio, 2.815 (1.781–4.449)], and a higher prevalence of post-traumatic stress disorder [aHR, 2.072 (1.408–3.050)]. High atrophy risk was associated with an increased risk of all-cause mortality [adjusted risk ratio, 3.19 (1.13–9.00)]. In sum, the high atrophy risk group displayed higher levels of previously identified risk factors and characteristics of cognitive impairment, including advanced age, symptoms of post-traumatic stress disorder, and prolonged duration of exposure to particulate matter. Thus, this study suggests that a high risk of brain atrophy may be accurately monitored using cognitive data., Dementia has a rising major impact on the health of ageing populations. World Trade Center responders are at increased risk for dementia, as characterized particularly by parietal-dominant cortical atrophy on neuroimaging. Clouston et al. used deep learning to predict the risk of developing cortical atrophy based on neuropsychological test results., Graphical abstract Graphical Abstract

Purpose To quantify the change resource utilization in radiation therapy in the context of advancing technologies and techniques over the last decade. Methods and Materials Prospectively, the time to complete radiation therapy workflow tasks was captured between January 1, 2020, and December 31, 2020. The institutional task workflows are specific to each technique and broadly organized into 4 categories: 3-dimenstional conformal radiation therapy, intensity modulated radiation therapy, volumetric modulated arc therapy simple, and volumetric modulated arc therapy complex. These discipline-specific task times were used to quantify a resource utilization factor, which is the median time taken to complete all tasks for each category divided by the median time for 3-dimensional conformal radiation therapy treatments. Retrospectively, all plans treated between January 1, 2012, and December 31, 2019, were quantified and categorized. The resource factor was applied to determine resource utilization. For context, institutional staffing levels were captured across the same decade for medical dosimetrists, medical physicists, and radiation oncologists. Results This analysis includes 30,229 patient plans in the retrospective data set and 4747 patient plans in the prospective data set. This analysis demonstrates that over this period, patient numbers increased by approximately 45%, whereas time-based human resources increased by almost 150%. The resource allocation factors for 3-dimenstional conformal radiation therapy, intensity modulated radiation therapy, volumetric modulated arc therapy simple, and volumetric arc therapy complex were 1.0, 2.4, 2.9, and 4.3, respectively. Across the 3 disciplines, staffing levels increased from 15 to 17 (13%) for medical dosimetrists, from 10 to 13 (30%) for medical physicists, and from 16 to 23 (44%) for radiation oncologists. Conclusions This work demonstrates the increase in resource utilization due to the introduction of advanced technologies and changes in radiation therapy techniques over the past decade. Human resource utilization is the predominant factor and should be considered with increasing patient volume for operational planning.

Transthoracic echocardiography (TTE) is the primary initial imaging modality in cardiac imaging. Advantages include portability, safety, availability, and ability to assess the morphology and physiology of the heart in a noninvasive manner. Because of this, many patients who undergo advanced imaging with CT or MRI will have undergone prior TTE, particularly when cardiac CT angiography or cardiac MRI is performed. In the modern era, the increasing interconnectivity of picture archiving and communication systems (PACS) has made these images more available for comparison. Therefore, radiologists who interpret chest imaging studies should have a basic understanding of TTE, including its strengths and limitations, to make accurate comparisons and assist in rendering a diagnosis or avoiding a misdiagnosis. The authors present the standard TTE views along with multiplanar reformatted CT images for correlation. This is followed by examples of limitations of TTE, focusing on potential blind spots, which have been placed in seven categories on the basis of the structures involved: (a) pericardium (thickening, calcification, effusions, cysts, masses), (b) aorta (dissection, intramural hematoma, penetrating atherosclerotic ulcer), (c) left ventricular apex (infarcts, aneurysms, thrombus, apical hypertrophic cardiomyopathy), (d) cardiac valves (complications of native and prosthetic valves), (e) left atrial appendage (thrombus), (f) coronary arteries (origins, calcifications, fistulas, aneurysms), and (g) extracardiac structures (primary and metastatic masses). Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. (©)RSNA, 2021

BACKGROUND Periodic breathing (PB) is common in preterm infants. We aimed to characterize the contribution of ventilatory control instability to the presence and persistence of PB longitudinally. METHODS Infants born between 28 and 32 weeks of gestation were studied using daytime polysomnography at: 32-36 weeks postmenstrual age (PMA) (N = 32), 36-40 weeks PMA (N = 20), 3 months corrected age (CA) (N = 18) and 6 months CA (N = 19). Loop gain, a measure of sensitivity of the ventilatory control system, was estimated by fitting a mathematical model to ventilatory patterns associated with spontaneous sighs. RESULTS The time spent in PB decreased from 32-36 weeks PMA to 6 months CA (P = 0.005). Across all studies, studies with PB (N = 62) were associated with higher loop gain compared to those without PB (N = 23) (estimated marginal mean ± SEM: 0.445 ± 0.01 vs 0.388 ± 0.02; P = 0.020). A threshold of loop gain >0.415 (measured at 32-36 weeks PMA) provided a sensitivity of 86% and a specificity of 75% to detect the presence of PB at 6 months CA. CONCLUSIONS The course of PB in preterm infants is related to changes in loop gain. Higher loop gain at 32-36 weeks PMA was associated with a greater risk of persistent PB at 6 months CA. IMPACT The developmental trajectory of periodic breathing and its relationship to ventilatory control instability is currently unclear. Unstable ventilatory control is a determinant of periodic breathing in preterm infants up to 6 months corrected age. Infants who display greater ventilatory control instability at 32-36 weeks postmenstrual age may be at increased risk of persistent periodic breathing at 6 months corrected age. Assessment of ventilatory control stability may assist in the early identification of infants at risk of persistent periodic breathing and its potential adverse effects.

Background Grip strength is a popular and valuable measure in studies of physical functional capabilities in old age. The influence of historical trends and differential period-specific exposures can complicate the interpretation of biomarkers of aging and health and requires careful analysis and interpretation of aging, birth cohort, and period effects. This study evaluates the effects of aging, period, and cohort on grip strength in a population of adults and older adults. Methods We use more than 27 000 observations for individuals at least 50 years of age, born in approximately 1910–1960, from the English Longitudinal Study of Ageing to examine a variety of multilevel and cross-classified modeling approaches to evaluate age, period, and cohort effects. Our results extended Hierarchical Age–Period–Cohort modeling and compared our results with a set of 9 submodels with explicit assumptions to determine the most reliable modeling approach. Results Findings suggest grip strength is primarily related to age, with minimal evidence of either period and/or cohort effects. Each year’s increase in a person’s age was associated with a 0.40-kg decrease in grip strength, though this decline differs by gender. Conclusions We conclude that as the population ages, grip strength declines at a systematic and predictable rate equal to −0.40 kg per year (approximately −0.50 kg for men and −0.30 kg for women) in residents of England aged 50 and older. Age effects were predominant and most consistent across methodologies. While there was some evidence for cohort effects, such effects were minimal and therefore indicative that grip strength is a consistent physiological biomarker of aging.

Introduction Flow limitation is the distinguishing characteristic of obstructive sleep apnoea. Critically, periods of flow limitation can occur without overt reductions in airflow (e.g. disproportionate increase in ventilatory drive vs. achieved ventilation), however, such periods are ignored by clinical scoring. Here we investigate flow limitation during so-called “stable breathing”, i.e. periods of sleep without scored events, by applying our recently-validated model to estimate flow limitation from the airflow signal. Methods Flow limitation was visually-scored (N=117,871 breaths) from N=40 participants attending an overnight sleep study for suspected sleep apnoea. Scoring was aided by physiological signals (e.g. intra-oesophageal diaphragm EMG). Model flow limitation classification used features extracted from the pneumotach signal (cross-validated accuracy=92.4%). We applied this method to investigate the occurrence of flow limitation during stable breathing, defined as periods of sleep >3 min duration without scored arousals or respiratory events. Results Model predicted flow limitation frequency was strongly correlated with visual scoring (R²=0.84 p Discussion Flow limitation occurs surprisingly frequently during stable breathing. While some individuals achieve stable breathing with minimal flow limitation, others demonstrate substantial flow limitation. Heterogeneity in frequency of flow limitation (within and between individuals) may provide further insights into emergent phenotypic variability within sleep disordered breathing. Finally, this model performed similarly in nasal pressure (88.2% accuracy), indicating potential application to clinical studies.

Introduction Continuous positive airway pressure (CPAP) delivered via oronasal masks are associated with lower adherence, higher residual AHI and CPAP requirement in comparison to nasal masks. Mechanisms contributing to increased CPAP requirement are not well understood. This physiological study aimed to assess the effect of mask type on upper airway anatomy and collapsibility. Methods 13 OSA patients, underwent a sleep study during which they wore both nasal and oronasal mask for half the night each (order randomized). CPAP was manually titrated to determine therapeutic pressure. Passive upper airway collapsibility was assessed using the Pcrit technique. Participants then underwent an MRI wearing both the nasal and oronasal mask. Cine MRI was used to dynamically assess cross-sectional area of the retroglossal airway across the respiratory cycle with each mask interface. Scans were repeated at 4cmH2O, as well as at the nasal and oronasal therapeutic pressures. Results The oronasal mask was associated with both higher therapeutic pressure requirements (∆M±SEM; +2.6±0.5, p Conclusions These preliminary findings suggest that oronasal masks worsen the collapsibility of the airway which likely contributes to the need for an elevated therapeutic pressure relative to nasal masks.

Background Patients with OSA can have the majority of their respiratory events in rapid eye movement (REM) sleep or in non-rapid eye movement (NREM) sleep. No previous studies have linked the different physiologic conditions in REM and NREM sleep to the common polysomnographic patterns seen in everyday clinical practice, namely REM predominant OSA (REMOSA) and NREM predominant OSA (NREMOSA). Research Question (1) How does OSA physiologic condition change with sleep stage in patients with NREMOSA and REMOSA? (2) Do patients with NREMOSA and REMOSA have different underlying OSA pathophysiologic conditions? Study Design and Methods We recruited patients with three polysomnographic patterns. (1) REMOSA: twice as many respiratory events in REM sleep, (2) NREMOSA: twice as many events in NREM sleep, and (3) uniform OSA: equal number of events in NREM/REM sleep. We deployed a noninvasive phenotyping method to determine OSA endotype traits (Vpassive, Vactive, loop gain, arousal threshold) in NREM sleep, REM sleep, and total night sleep in each group of patients (NREMOSA, REMOSA, uniform OSA). Results Patients with NREMOSA have significantly worse ventilatory control stability in NREM sleep compared with REM sleep (loop gain, 0.546 [0.456,0.717] in NREM vs 0.365 [0.238,0.459] in REM sleep; P = .0026). Patients with REMOSA displayed a significantly more collapsible airway (ie, lower Vpassive) in REM compared with NREM sleep (98.4 [97.3,99.2] %Veupnea in NREM vs 95.9 [86.4,98.9] %Veupnea in REM sleep; P Interpretation This study is the first to link long-recognized polysomnographic patterns of OSA to underlying physiologic differences. Patients with NREMOSA have a higher loop gain in NREM sleep; patients with REMOSA have a worsening of Vpassive in REM sleep.

Obstructive sleep apnoea (OSA) is a significant public health problem, with comorbidities including excessive daytime sleepiness, increased risk of motor vehicle accidents, cardiovascular disease, cognitive impairment, and decreased quality of life. OSA is characterised by intermittent periods of pharyngeal obstruction resulting in the absence (apnoea) or reduction (hypopnoea) of airflow during sleep. OSA severity is currently reported by the apnoea-hypopnoea index (AHI): the frequency of apnoeas and hypopnoeas per hour of sleep. However, the AHI is a poor predictor of an individual’s day to day performance, symptomology and long-term health outcomes. This is likely due to a limitation with the event-based AHI, which inadequately describes the underlying neuro-mechanical airway resistance that leads to pharyngeal obstruction, and as such, does not capture the severity of airflow obstruction.Therefore, the overarching goal of this thesis is to develop non-invasive methods to objectively characterise the severity of airflow obstruction on a breath-by-breath basis.Previous literature has identified characteristics within the airflow signal that may indicate airflow obstruction. However, analysis of these features on a breath-by-breath basis requires accurate demarcation of “breath timing” (i.e. inspiratory and expiratory phases). As such, the first aim of this thesis was to develop methods that accurately demarcate breaths. We segmented breaths into inspiratory (TI, shortest period achieving 95% inspiratory volume), expiratory (TE, shortest period achieving 95% expiratory volume), and an inter-breath transition period (TTrans, the period between TE and subsequent TI). In a cohort of 37 patients with an epiglottic pressure catheter, we observed that compensatory increases in the inspiratory period (1.57±0.27 vs 1.74±0.27 seconds, mean±SD, P≤0.001) from reference breaths to partial airway obstruction (identified by increasing epiglottic pressure swings without increasing airflow) were primarily explained by reductions in the inter-breath transition period (0.82±0.28 vs 0.59±0.21 seconds, mean±SD, P≤0.001) and not by reduction of the expiratory airflow period (1.68±0.32 vs 1.60±0.25 seconds, mean±SD, P≤0.05). In addition to developing a method for demarcating breaths, we also identify TTrans as a novel feature associated with increased airway obstruction.Using our newly developed breath timing method in conjunction with the other known markers of flow limitation, we then aimed to characterise the flow shape of individual breaths to develop a transparent machine learning strategy for the non-invasive quantification of the severity of airflow obstruction. We defined gold-standard obstruction severity as the ratio of oronasal pneumotach (flow) and ventilatory drive (calibrated intra-oesophageal diaphragm EMG, drive), presented as a continuous breath-by-breath variable, flow:drivemeasured. Multivariable linear regression used non-invasive flow-shape features (inspiratory/expiratory timing, flatness, scooping, fluttering) to model flow:drivemeasured in 136,264 breaths from 41 patients (with pneumotach and intra-oesophageal diaphragm EMG). We observed flow:drivemeasured varying widely across individuals independent of AHI. A multivariable model (25 features) estimated obstruction severity (flow:driveestimated) breath-by-breath (R2=0.58 vs. flow:drivemeasured, P

Birth weight and early growth have been associated with later blood pressure. However, not all studies consistently find a significant reduction in blood pressure with an increase in birth weight. In addition, the relative importance of birth weight and of other lifestyle and environmental factors is often overlooked and the association is rarely studied in adolescents. We investigated early life predictors, including birth weight, of adolescent blood pressure in the Gateshead Millennium Study (GMS). The GMS is a cohort of 1029 individuals born in 1999–2000 in Gateshead in Northern England. Throughout infancy and early childhood, detailed information were collected, including birth weight and measures of height and weight. Assessments of 491 returning participants at age 12 years included measures of body mass and blood pressure. Linear regression and path analysis were used to determine predictors and their relative importance on blood pressure. Birth weight was not directly associated with blood pressure at the age of 12. However, after adjustment for contemporaneous body mass index (BMI), an inverse association of standardized birth weight on systolic blood pressure was significant. The relative importance of birth weight on later systolic blood pressure was smaller than other contemporaneous body measures (height and BMI). There was no independent association of birth weight on blood pressure seen in this adolescent population. Contemporaneous body measures have an important role to play. Lifestyle factors that influence body mass or size, such as diet and physical activity, where interventions are directed at early prevention of hypertension should be targeted.

Background The association between Free Sugars intake and non-communicable diseases such as obesity and dental caries is well documented and several countries are taking measures to reduce sugars intakes. Public Health England (PHE) instigated a range of approaches to reduce sugars, including a national health marketing campaign (Sugar Smart). The campaign aimed to raise awareness of the amount of sugars in foods and drinks and to encourage parents to reduce their children’s intake. The aim of this study was to determine whether the campaign was effective in altering dietary behaviour, by assessing any impact of the campaign on sugars intake among children aged 5–11 years. Parental perceptions of the campaign and barriers to reducing sugars intake were also explored. Methods Parents of 873 children aged 5–11 years, identified from an existing PHE database, were invited to take part. Dietary information was collected online using Intake24 before, during, and at 1, 10 and 12 months following the campaign. Change in sugars intake was assessed using mixed effects linear regression models. One-to-one telephone interviews were conducted with a purposive sample of parents to explore perceptions of the campaign and identify barriers and facilitators to reducing children’s sugars intake. Results Completion rates for dietary assessment ranged from 61 to 72% across the follow up time points. Qualitative telephone interviews were conducted with 20 parents. Total sugars intake decreased on average by ~ 6.2 g/day (SD 43.8) at peak campaign and the percentage of energy from total sugars significantly decreased immediately and 1 year post campaign. The percentage of energy from Free Sugars significantly decreased across all time points with the exception of the long term follow up at 12-months post campaign. The percentage of energy intake from total fat increased. Parents expressed a willingness to reduce sugars intakes, however, identified barriers including time constraints, the normalisation of sugary treats, and confusing information. Conclusions A health marketing campaign had a positive impact in reducing sugars intake but reductions in sugars were not sustained. Parents want to reduce their child’s sugars intake but societal barriers and confusion over which sources of sugars to avoid hamper efforts to change.

Objective Subthreshold psychosis risk symptoms in the general population may be associated with molecular genetic risk for psychosis. This study sought to optimize the association of risk symptoms with genetic risk for psychosis in a large population-based cohort in the UK (N = 9104 individuals 18–65 years of age) by properly accounting for population stratification, factor structure, and sex. Methods The newly expanded Generation Scotland: Scottish Family Health Study includes 5391 females and 3713 males with age M [SD] = 45.2 [13] with both risk symptom data and genetic data. Subthreshold psychosis symptoms were measured using the Schizotypal Personality Questionnaire-Brief (SPQ-B) and calculation of polygenic risk for schizophrenia was based on 11 425 349 imputed common genetic variants passing quality control. Follow-up examination of other genetic risks included attention-deficit hyperactivity disorder (ADHD), autism, bipolar disorder, major depression, and neuroticism. Results Empirically derived symptom factor scores reflected interpersonal/negative symptoms and were positively associated with polygenic risk for schizophrenia. This signal was largely sex specific and limited to males. Across both sexes, scores were positively associated with neuroticism and major depressive disorder. Conclusions A data-driven phenotypic analysis enabled detection of association with genetic risk for schizophrenia in a population-based sample. Multiple polygenic risk signals and important sex differences suggest that genetic data may be useful in improving future phenotypic risk assessment.

If a user-centered approach is not used to design information displays, the quantity and quality of information presented to the user may not match the needs of the user, or it may exceed the capability of the human operator for processing and using that information. The result may be an excessive mental workload and reduced situation awareness of the operator, which can negatively affect the machine performance and operational outcomes. The increasing use of technology in agricultural machines may expose the human operator to excessive and undesirable information if the operator’s information needs and information processing capabilities are ignored. In this study, a user-centered approach was used to design specific interface elements for an agricultural air seeder. Designs of the interface elements were evaluated in a laboratory environment by developing high-fidelity prototypes. Evaluations of the user interface elements yielded significant improvement in situation awareness (up to 11%; overall mean difference = 5.0 (4.8%), 95% CI (6.4728, 3.5939), p < 0.0001). Mental workload was reduced by up to 19.7% (overall mean difference = -5.2 (-7.9%), n = 30, a = 0.05). Study participants rated the overall performance of the newly designed user-centered interface elements higher in comparison to the previous designs (overall mean difference = 27.3 (189.8%), 99% CI (35.150, 19.384), p < 0.0001). Keywords: Agricultural machines, Interface design principles, Situation awareness, User-centered design, User interface design, User experience.

Introduction The relationship between sleep duration and loneliness among healthy older adults is not fully understood. Shorter sleep duration and increased variability of sleep timing (sleep onset and wake time) have recently been shown to have adverse health outcomes in younger adults. While physiological stressors associated with loneliness are likely distinct, we hypothesise that older adults who identify as lonely have reduced sleep duration and increased variability of sleep timing. Methods Older individuals (N=60) without significant co-morbidities were recruited via convenience sampling. Participants completed the de Jong Giervield Loneliness Scale and wore an actigraph for up to 2 weeks. Sleep metrics from actigraphy (sleep onset and wake times, and SD) were determined by algorithm assisted human scoring. Results Valid data was retrieved from N=37 participants (age 83±6.8 years [mean±SD]). There were no significant differences in demographics between those in the lonely (N=19) and not lonely (N=18) groupings. There was substantial heterogeneity in individual participant’s sleep metrics, both within and between groupings. The average sleep onset time was similar between groups, however lonely participants typically woke earlier resulting in slightly shorter sleep duration. Variability in sleep onset and wake times was reduced in lonely participants. Discussion While shorter sleep duration was expected, we did not anticipate the reduction in sleep timing variability amongst those defined as lonely; more regular sleep periods have previously been associated with better outcomes. We did not see statistically significant differences between our groups, possibly due to sample size limitations, however, the unexpected trend warrants further investigation.

Background Early warning tools identify patients at risk of deterioration in hospitals. Electronic medical records in hospitals offer real-time data and the opportunity to automate early warning tools and provide real-time, dynamic risk estimates. Objective This review describes published studies on the development, validation, and implementation of tools for predicting patient deterioration in general wards in hospitals. Methods An electronic database search of peer reviewed journal papers from 2008-2020 identified studies reporting the use of tools and algorithms for predicting patient deterioration, defined by unplanned transfer to the intensive care unit, cardiac arrest, or death. Studies conducted solely in intensive care units, emergency departments, or single diagnosis patient groups were excluded. Results A total of 46 publications were eligible for inclusion. These publications were heterogeneous in design, setting, and outcome measures. Most studies were retrospective studies using cohort data to develop, validate, or statistically evaluate prediction tools. The tools consisted of early warning, screening, or scoring systems based on physiologic data, as well as more complex algorithms developed to better represent real-time data, deal with complexities of longitudinal data, and warn of deterioration risk earlier. Only a few studies detailed the results of the implementation of deterioration warning tools. Conclusions Despite relative progress in the development of algorithms to predict patient deterioration, the literature has not shown that the deployment or implementation of such algorithms is reproducibly associated with improvements in patient outcomes. Further work is needed to realize the potential of automated predictions and update dynamic risk estimates as part of an operational early warning system for inpatient deterioration.

Pipeline programs address health disparities by promoting academic achievement and entry of low-income ethnic and racial minority youth into healthcare fields. The Health Career Academy (HCA) is a 3-year pipeline program for high school students from low-income, ethnic, and racial minority communities. Health professional students serve as program mentors. The HCA has been implemented in nine US sites, with partnerships between 17 health professional schools and 17 high schools. A total of 386 10th grade students and 95 11th grade students enrolled as participants in the 2015-2016 HCA program. In post-participation surveys, 10th grade students reported that the HCA helped them learn about different healthcare career options, plan for how to reach career goals, and understand how healthcare workers care for patients. Eleventh grade participants noted the program made them aware of the importance of public health and taught them about medical conditions, self-care, and safety. Eighty-six percent of 10th graders and 71% of 11th graders reported that they are considering healthcare careers. Students' favorite aspects of the HCA included the following: time with mentors, learning about science and health, team collaboration and hands-on experiences, field trips, and team presentations. Teachers noted the following as most important in the program: interaction with mentors and healthcare professionals, learning broadly applicable skills, stimulation of interest in health-related careers, presentation skills, and creating optimism about furthering education. The HCA is well received by participants and can be replicated successfully at multiple sites nationally. By providing mentorship, increasing exposure to health professionals and health careers, offering high-level science and health curriculum, and fostering collaboration and presentation skills, the HCA has potential to increase interest in health professions among racial and ethnic minority youth from low-income communities.

Background and objective: Obstructive sleep apnoea (OSA) is typically worse in the supine versus lateral sleeping position. One potential factor driving this observation is a decrease in lung volume in the supine position which is expected by theory to increase a key OSA pathogenic factor: dynamic ventilatory control instability (i.e. loop gain). We aimed to quantify dynamic loop gain in OSA patients in the lateral and supine positions, and to explore the relationship between change in dynamic loop gain and change in lung volume with position.

In this work we demonstrate, a high brightness, high transmission Pump Signal Combiner (PSC) operating at 2.1 kW for 10 minutes mounted on a metal plate without running cooling water (Passively Cooled). The 6+1 to 1 PSC tested in this work has six 247 μm cladding diameter 0.22NA pump pigtails, a 10/125um signal pigtail and a 20/400um double clad output fiber. The combiners achieve a high pump transmission efficiency of 98%. During the passively cooled highpower test conducted at a power of 2.1 kW the maximum temperature recorded on the surface of the package was at a temperature of 38.5°C for 10min of power aging.

STUDY OBJECTIVES: Body posture has a significant impact on the presence and severity of obstructive sleep apnea (OSA). The majority of polysomnography (PSG) systems have the capacity to categorize body (torso) posture as supine, left-lateral, right-lateral or prone, each within a 90-degree range. However, such broad categorization may limit the identification of subtle relationships between posture and OSA severity. The aim of this study was to quantify sleeping posture as a continuous variable; and to develop an intuitive tool for visualizing the relationship between body posture and OSA severity. METHODS: A customized triaxial accelerometer-based posture sensor which quantifies torso posture as a continuous variable was developed. 38 participants attending the sleep laboratory for suspected OSA were recruited. Each participant underwent a diagnostic PSG with an additional customized posture sensor securely attached to the sternum. Individual data were presented using a novel circular histogram-based visualization which displays sleeping position and position-specific OSA severity. RESULTS: Acceptable measurements were obtained in 21 participants. The mean ± standard deviation percentage of total sleep time spent within ± 15 degrees of the center of supine, left-lateral, right-lateral and prone was 59.7 ± 26.0%. A further 40.3 ± 26.0% of sleep time was spent in intermediate positions outside these traditional categorizations. The novel visualization revealed a wide variety of positional OSA phenotypes. CONCLUSIONS: Quantification of torso posture as a continuous variable and analysis of these data using a novel visualization enables the identification of subtle relationships between body posture and OSA severity that are not apparent using standard clinical sensors and summary statistics. CITATION: Tate A, Walsh J, Kurup V, Shenoy B, Mann D, Freakley C, Eastwood P, Terrill P. An emerging technology for the identification and characterization of postural-dependent obstructive sleep apnea. J Clin Sleep Med. 2020;16(2):309–318.

Purpose To characterize the accuracy and consistency of fluoroscope dose index reporting and report rates of occupational radiation safety hardware availability and use, trainee participation in procedures, and optional hardware availability at pilot sites for the American College of Radiology (ACR) Fluoroscopy Dose Index Registry (DIR). Materials and Methods Nine institutions participated in the registry pilot, providing fluoroscopic technical and clinical practice data from 38 angiographic C-arm–type fluoroscopes. These data included measurements of the procedure table and mattress transmission factors and accuracy measurements of the reference-point air kerma (Ka,r) and air kerma–area product (PKA). The accuracy of the radiation dose indices were analyzed for variation over time by 1-way analysis of variance (ANOVA). Sites also self-reported information on availability and use of radiation safety hardware, hardware configuration of fluoroscopes, and trainee participation in procedures. Results All Ka,r and PKA measurements were within the ±35% regulatory limit on accuracy. The mean absolute difference between correction factors for a given system in fluoroscopic and acquisition mode was 0.03 (95% confidence interval, 0.03–0.03). For the 28 fluoroscopic imaging planes that provided data for 3 time points, ANOVA yielded an F value of 0.134 with an F-critical value of 3.109 (P = .875). Conclusions This publication provides the technical and clinical framework pertaining to the ACR Fluoroscopy DIR pilot and offers necessary context for future analysis of the clinical procedure radiation-dose data collected.

ImportanceSubthreshold psychosis symptoms in the general population may be associated with genetic risk for schizophrenia. In this analysis, empirically-derived symptom factor scores led to a detection of significant and robust polygenic signal.ObjectiveThis study sought to optimize genetic association with data-driven symptom factor scores, accounting for cohort factor structure and sex differences.DesignEFA-derived symptom factor scores were regressed onto PRS for schizophrenia in models accounting for age and genetic ancestry principal components. Follow-up examination of symptom factor score associations with other related genetic risks included ADHD, autism, bipolar disorder, major depression, and neuroticism.ParticipantsThis study examined the newly expanded symptom dataset from the Northern European ancestry cohort, Generation Scotland: Scottish Family Health Study (N = 9,105 individuals 18-65 years of age) comprising common variant and subthreshold psychosis symptom data. A total of 5,391 females and 3,713 males with age M[SD] = 45.2 [13] were included in the final analyses.Main Outcome and MeasureSubthreshold psychosis symptoms were measured using the Schizotypal Personality Questionnaire-Brief (SPQ-B). Primary phenotypic factor scores and genome-wide polygenic risk scores (PRS) reflected weighted sum scores and were examined as continuous measures. Polygenic risk scores were calculated from genome-wide association summary statistics using 7,358,674 imputed common genetic variants passing quality control.ResultsIn males, symptom factor scores were positively associated with polygenic risk for schizophrenia alone and implicated primarily interpersonal/negative symptoms. In females, symptom factor scores were positively associated with polygenic risks for ADHD and autism but not schizophrenia. Scores were robustly associated with genetic risk for neuroticism across both males and females.Conclusions and RelevanceThis study detected a significant association of subthreshold psychosis symptoms with genetic risk for schizophrenia and neuroticism in a population-based sample. Furthermore, important sex differences suggest a need for better understanding of schizophrenia risk assessment in females.Key PointsQuestionWhat molecular genetic risks are associated with subthreshold psychosis symptoms in the general population?FindingsIn a large population-based cohort (N = 9,084), significant associations of polygenic risks with symptoms were observed. Symptoms were associated with genetic risk for schizophrenia in males, for ADHD and autism spectrum disorder in females, and for neuroticism across both males and females.MeaningAssociations of genetic risk with symptoms in the general population are highly significant and suggest important sex differences.

Background As young people with long-term conditions move from childhood to adulthood, their health may deteriorate and their social participation may reduce. ‘Transition’ is the ‘process’ that addresses the medical, psychosocial and educational needs of young people during this time. ‘Transfer’ is the ‘event’ when medical care moves from children’s to adults’ services. In a typical NHS Trust serving a population of 270,000, approximately 100 young people with long-term conditions requiring secondary care reach the age of 16 years each year. As transition extends over about 7 years, the number in transition at any time is approximately 700. Objectives Purpose – to promote the health and well-being of young people with long-term conditions by generating evidence to enable NHS commissioners and providers to facilitate successful health-care transition. Objectives – (1) to work with young people to determine what is important in their transitional health care, (2) to identify the effective and efficient features of transitional health care and (3) to determine how transitional health care should be commissioned and provided. Design, settings and participants Three work packages addressed each objective. Objective 1. (i) A young people’s advisory group met monthly throughout the programme. (ii) It explored the usefulness of patient-held health information. (iii) A ‘Q-sort’ study examined how young people approached transitional health care. Objective 2. (i) We followed, for 3 years, 374 young people with type 1 diabetes mellitus (150 from five sites in England), autism spectrum disorder (118 from four sites in England) or cerebral palsy (106 from 18 sites in England and Northern Ireland). We assessed whether or not nine proposed beneficial features (PBFs) of transitional health care predicted better outcomes. (ii) We interviewed a subset of 13 young people about their transition. (iii) We undertook a discrete choice experiment and examined the efficiency of illustrative models of transition. Objective 3. (i) We interviewed staff and observed meetings in three trusts to identify the facilitators of and barriers to introducing developmentally appropriate health care (DAH). We developed a toolkit to assist the introduction of DAH. (ii) We undertook a literature review, interviews and site visits to identify the facilitators of and barriers to commissioning transitional health care. (iii) We synthesised learning on ‘what’ and ‘how’ to commission, drawing on meetings with commissioners. Main outcome measures Participation in life situations, mental well-being, satisfaction with services and condition-specific outcomes. Strengths This was a longitudinal study with a large sample; the conditions chosen were representative; non-participation and attrition appeared unlikely to introduce bias; the research on commissioning was novel; and a young person’s group was involved. Limitations There is uncertainty about whether or not the regions and trusts in the longitudinal study were representative; however, we recruited from 27 trusts widely spread over England and Northern Ireland, which varied greatly in the number and variety of the PBFs they offered. The quality of delivery of each PBF was not assessed. Owing to the nature of the data, only exploratory rather than strict economic modelling was undertaken. Results and conclusions (1) Commissioners and providers regarded transition as the responsibility of children’s services. This is inappropriate, given that transition extends to approximately the age of 24 years. Our findings indicate an important role for commissioners of adults’ services to commission transitional health care, in addition to commissioners of children’s services with whom responsibility for transitional health care currently lies. (2) DAH is a crucial aspect of transitional health care. Our findings indicate the importance of health services being commissioned to ensure that providers deliver DAH across all health-care services, and that this will be facilitated by commitment from senior provider and commissioner leaders. (3) Good practice led by enthusiasts rarely generalised to other specialties or to adults’ services. This indicates the importance of NHS Trusts adopting a trust-wide approach to implementation of transitional health care. (4) Adults’ and children’s services were often not joined up. This indicates the importance of adults’ clinicians, children’s clinicians and general practitioners planning transition procedures together. (5) Young people adopted one of four broad interaction styles during transition: ‘laid back’, ‘anxious’, ‘wanting autonomy’ or ‘socially oriented’. Identifying a young person’s style would help personalise communication with them. (6) Three PBFs of transitional health care were significantly associated with better outcomes: ‘parental involvement, suiting parent and young person’, ‘promotion of a young person’s confidence in managing their health’ and ‘meeting the adult team before transfer’. (7) Maximal service uptake would be achieved by services encouraging appropriate parental involvement with young people to make decisions about their care. A service involving ‘appropriate parental involvement’ and ‘promotion of confidence in managing one’s health’ may offer good value for money. Future work How might the programme’s findings be implemented by commissioners and health-care providers? What are the most effective ways for primary health care to assist transition and support young people after transfer? Study registration This study is registered as UKCRN 12201, UKCRN 12980, UKCRN 12731 and UKCRN 15160. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

Objective The purpose of this study was to investigate the extent of agreement between physicians and patients in reporting ocular history and to determine whether there are any predictive factors for physician–patient consensus. Design Retrospective chart review. Participants Between June and September 2014, adult patients undergoing cataract surgery were recruited for the study. Methods Before surgery, patient demographics and self-reported ocular history were extracted from a prospectively collected database. Medical charts were retrospectively examined to retrieve physician-reported ocular history. Results One hundred and thirty-eight patients participated. Mean cohort logMAR visual acuity was 0.46 ± 0.34 (Snellen equivalent of approximately 20/60) and mean age was 74.1 ± 8.3 years. For glaucoma, Cohen's kappa revealed a moderate-to-good concordance between physicians and patients (κ = 0.604), whereas a poor-to-fair level of agreement existed in reporting maculopathy, such as age-related macular degeneration and macular holes (κ = 0.254). The logistic regression model revealed that preoperative visual acuity ( p = 0.223), sex ( p = 0.736), age ( p = 0.910), and education ( p = 0.738) were not significant predictors of physician–patient agreement. Conclusions The accuracy of patient-reported ocular history varies by pathology. Self-reported glaucoma history is consistent between patients and physicians; however, patients under-report the diagnosis of maculopathy. Age, sex, and level of education do not appear to influence patient-reported accuracy of ocular comorbidities.

Background: Marine-derived ω-3 fatty acids (ω-3FAs) have proven antitumor activity in vivo and in vitro and improve quality of life (QOL) in clinical cancer studies. These changes may be mediated by reduction in circulating proangiogenic and proinflammatory factors. In this first study of intravenous ω-3FAs as a therapy in cancer patients, we aimed to assess if it could augment the antitumor activity of gemcitabine in patients with advanced pancreatic cancer and improve QOL. Materials and Methods: Patients were administered gemcitabine 1000 mg/m3 weekly followed by up to 100 g (200 mg/mL) of ω-3 rich lipid emulsion for 3 weeks followed by a rest week. This was continued for up to 6 cycles, progression, unacceptable toxicity, patient request, or death. The primary outcome measure was objective response rate, with secondary outcome measures of overall and progression free survival, QOL scores, and adverse events. Results: Fifty patients were recruited. Response rate was 14.3% and disease control rate was 85...

Background Prone extralevator abdominoperineal excision of the rectum (ELAPE) has been introduced to improve the circumferential resection margins (CRM) compared with traditional APER. Objective We present short-term results achieved with prone ELAPE preceded by neoadjuvant chemoradiotherapy during the last 5 years of activity. Design A retrospective review was conducted. Settings and patients Prone ELAPE operations performed between September 2010 and August 2014 at Leicester Royal Infirmary preceded by neoadjuvant chemoradiotherapy. Interventions and main outcome measures Data regarding demographics, staging, neoadjuvant therapies, intraoperative perforations, and perineal complications were collected. Results Seventy-two patients were included. Pretreatment radiological T4 were 25.0%, histological T4 2.8%. Intraoperative perforations occurred in 2.8%, CRM was involved in 11.1%. Perineal complications consisted of superficial wound infections (20.8%), full thickness dehiscences (16.7%), hematomas (9.7%), pelvic collections (6.9%), and perineal hernias (5.6%). Conclusions In our experience, prone ELAPE preceded by long-course chemoradiotherapy has been successfully used in the last 5 years to resect low rectal tumors. Perineal wound complications rates are similar to those presented in series using direct perineal closures. J. Surg. Oncol. 2016;114:86-90. © 2016 Wiley Periodicals, Inc.

With its recent inclusion in the Diagnostic and Statistical Manual, nonsuicidal self-injury disorder (NSSID) has received limited research attention, especially in samples of military veterans. The present study sought to identify diagnostic predictors of NSSID within a veteran sample. Study participants included 124 veterans with at least one psychiatric diagnosis. Chi-square tests and t-tests evaluated bivariate associations between NSSID and twenty diagnostic correlates. Logistic regression models identified psychiatric disorders that were unique correlates of NSSID among veterans. Veterans with lifetime NSSID (n = 59) met criteria for a greater number of lifetime disorders than veterans with other psychiatric disorders. Bivariate associations were noted between NSSID and borderline personality disorder, depression, obsessive-compulsive disorder, generalized anxiety disorder, and cannabis use disorder. In the logistic regression model, only borderline personality disorder (AOR = 7.67) and obsessive-compulsive disorder (AOR = 3.23) continued to be associated with NSSID. The present study represents the first examination of the association between NSSID and psychiatric disorders among veterans. The findings shed light on psychiatric disorders associated with lifetime NSSID in veterans, with special consideration toward obsessive-compulsive disorder as a risk factor for NSSID.

Low parasympathetic regulation of cardiac activity, known as cardiac vagal control (CVC), is robustly associated with poor health outcomes. However, the etiological mechanism that undergirds this association remains largely unknown. One explanation is a causal relationship wherein health problems cause low CVC, or vice versa. However, an alternative explanation is that a common set of genetic factors contributes to both increased liability for poor health and low CVC (i.e., pleiotropy). The present study uses polygenic risk scores for a number of health-related phenotypes (physical, mental, behavioral) to test whether genetic liability for poor health has pleiotropic effects on CVC. We report evidence for shared genetic liability between low CVC and both poor physical health (elevated triglycerides) and risky health-related behaviors (increased drinking and sexual activity). The present findings are consistent with shared genetic liability explaining, at least in part, the well-documented correlation between CVC and health.

This study was designed as an exploratorycase study to determine the relative importance anddependencies of the CEAB graduate attributes asperceived by engineering stakeholders of the University ofManitoba. The findings were used to examine the contentvalidity of the Biosystems Engineering program. Theoverarching objective was to explore how well theemphasis on graduate attributes development in theFaculty of Engineering at the University of Manitobareflect the graduate attribute importance reported by keystakeholders. Findings showed that all stakeholdersranked Individual and Teamwork and CommunicationsSkills as the top engineering competencies, and all CEABgraduate attributes were perceived to between 6.1% and10.9% relatively important. This was in sharp contrast tothe Biosystems Engineering program, which is comprisedof approximately 50% of the graduate attribute, AKnowledge Base for Engineering. In this paper, themethods and findings in the determination of the contentvalidity of an engineering program are presented anddiscussed.