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Driver status monitoring systems are a vital component of smart cars in the future, especially in the era when an increasing amount of time is spent in the vehicle. The heart rate (HR) is one of the most important physiological signals of driver status. To infer HR of drivers, the mainstream of the existing research focused on capturing subtle heartbeat-induced vibration of the torso or leveraged photoplethysmography (PPG) that detects cardiac cycle-related blood volume changes in the microvascular. However, existing approaches rely on dedicated sensors that are expensive and cumbersome to be integrated or are vulnerable to ambient noise. Moreover, their performance on the detection of HR does not guarantee a reliable computation of the HR variability (HRV) measure, which is a more applicable metric for inferring mental and physiological status. The accurate computation HRV measure is based on the precise measurement of the beat-to-beat interval, which can only be accomplished by medical-grade devices that attach electrodes to the body. Considering these existing challenges, we proposed a facial expression-based HRV estimation solution. The rationale is to establish a link between facial expression and heartbeat since both are controlled by the autonomic nervous system. To solve this problem, we developed a tree-based probabilistic fusion neural network approach, which significantly improved HRV estimation performance compared to conventional random forest or neural network methods and the measurements from smartwatches. The proposed solution relies only on commodity camera with a lightweighted algorithm, facilitating its ubiquitous deployment in current and future vehicles. Our experiments are based on 3400 km of driving data from nine drivers collected in a naturalistic field study.

Background Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. Methods Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups. Results Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016). Conclusion In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.

OBJECTIVE: Patients who experience homelessness and have mental illness can have frequent and challenging hospitalizations. Nurses caring for this vulnerable population may have negative attitudes, which can be mitigated by education and improved for the benefit of patients. This study aimed to assess the impact of an educational intervention on the attitudes of nursing staff toward individuals experiencing homelessness and mental illness. METHODS: Using a pre–post design, a revised version of the Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI) assessed 23 nursing staff working on inpatient medicine units surrounding a brief educational session about persons experiencing homelessness and mental illness. Data were also collected from open-ended questions. RESULTS: There was a small positive increase in mean HPATHI scores postintervention (74.783 [ SD = 5.485] to 77.13 [ SD = 6.312]) indicating more positive participant attitudes toward homeless individuals. The HPATHI also revealed a 6% increase in score for participant comfortability providing care for homeless persons with major mental illness postintervention. Some participants likely interpreted their answers as displaying more positive and less cynical attitudes based on their comments, while the HPATHI scored them as more negative. Qualitative feedback revealed both positive and negative attitudes toward this patient population, and various associated barriers to care. CONCLUSIONS: Nursing staff will likely provide care for patients who experience homelessness with concomitant mental illness. Educating nurses about the needs of this population is feasible and could be beneficial for patient care.

Purpose Radiation therapy is a valuable, yet time- and resource-intense therapy. Patients experiencing homelessness (PEH) face many barriers related to the timely receipt of radiation therapy. Owing to a paucity of data regarding cancer treatment and homelessness, clinicians have a limited evidence base when recommending therapy to PEH. This study was performed to evaluate adherence to radiation therapy treatment regimens in PEH with cancer. Methods and Materials The study cohort was primarily derived from the Vanderbilt University Medical Center Homeless Health Services program. Patients in the Homeless Health Services program with radiation oncology visits were identified by query of the electronic medical record. Manual chart review was performed to gather standard treatment parameters and data describing missed appointments. A comparison group of patients not experiencing homelessness (non-PEH) was generated by aggregating appointment data for all other patients receiving similar treatments at Vanderbilt University Medical Center during multiple, consecutive years. Results In the study, 3408 PEH were identified, of whom 48 underwent radiation oncology consultation. Thirty-two were prescribed at least 1 course of radiation therapy, for a total of 54 unique courses. Out of these courses, 34 (62.9%) were completed as prescribed without delay, 12 (22.2%) were completed with delay(s), and 8 (14.8%) were not fully completed. Although the PEH cohort had significantly higher rates of delayed and undelivered fractions, the proportion of delayed or incomplete courses was not significantly different from the comparison group of non-PEH, particularly for courses with 10 or fewer fractions. Reasons for missed appointments for PEH were variable. Conclusions This is the first publication describing adherence to radiation therapy in PEH. Our data suggest that PEH are as likely as non-PEH to complete a course of radiation therapy, albeit with more treatment interruptions. When treatment courses of >10 fractions are expected, PEH may benefit from more hypofractionated regimens, provided they have equivalent clinical efficacy to longer regimens. Documenting reasons for missed appointments will be essential to further understanding the needs of PEH. This study serves as a foundation for further analysis regarding homelessness and radiation therapy.

Background : Accurate risk stratification of critically ill patients with coronavirus disease 2019 (COVID-19) is essential for optimizing resource allocation, delivering targeted interventions, and maximizing patient survival probability. Machine learning (ML) techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care. Methods : We retrieved data on patients with COVID-19 admitted to an intensive care unit (ICU) between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry. We applied the Extreme Gradient Boosting (XGBoost) algorithm to the data to predict as a binary outcome the increase or decrease in patients’ Sequential Organ Failure Assessment (SOFA) score on day 5 after ICU admission. The model was iteratively cross-validated in different subsets of the study cohort. Results : The final study population consisted of 675 patients. The XGBoost model correctly predicted a decrease in SOFA score in 320/385 (83%) critically ill COVID-19 patients, and an increase in the score in 210/290 (72%) patients. The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model {0.86 vs. 0.69, P

Introduction The nature of nocturnal cough is largely unknown. It might be a valid marker for asthma control but very few studies characterized it as a basis for better defining its role and its use as clinical marker. This study investigated prevalence and characteristics of nocturnal cough in asthmatics over the course of four weeks. Methods In two centers, 94 adult patients with physician-diagnosed asthma were recruited. Patient-reported outcomes and nocturnal sensor data were collected by a smartphone with a chat-based study app. Results Patients coughed in 53% of 2212 nights (range: 0-345 coughs/night). Median coughs per hour were 0 (IQR 0-1). Nocturnal cough rates showed considerable inter-individual variance. The highest counts were measured in the first 30 min in bed (4.5-fold higher than rest of night). Eighty-six percent of coughs were part of a cough cluster. Clusters consisted of a median of two coughs (IQR 2-4). Nocturnal cough was persistent within patient. Conclusion To the best of the authors' knowledge, this study is the first to describe prevalence and characteristics of nocturnal cough in asthma over a period of one month, demonstrating that it was a prevalent symptom with large variance between patients and high persistence within patients. Cough events in asthmatics were 4.5 times more frequent within the first 30 min in bed indicating a potential role of positional change, and not more frequent during the early morning hours. An important next step will investigate the association between nocturnal cough and asthma control.

Background Diagnostic delay of breast cancer related to the false-negative assessment of the healthcare provider leads to tumor progression and might worsen the outcome. Previous studies found some factors associated with provider-related diagnostic delay; however, tumor biology has tended not to be considered. The aim of our study was to find differences in diagnostic delay of poorly differentiated breast cancer types. Methods Data of 970 patients with newly diagnosed moderately/poorly differentiated (G2/3) breast cancer at the age ≥40 years was retrospectively analyzed regarding breast cancer type, diagnostic delay and its consequence, clinical factors and physician’s assessment. Multivariate analysis was used to evaluate associated factors with diagnostic delay. Results We observed a diagnostic delay in 3.8% (n = 37) of all patients. Mean delay time was 128 days, and clinically relevant tumor growth was observed in 43.2% of these cases. Delay was significantly higher in the group of triple-negative breast cancer (9.9% versus 2.7, 5.3 and 1.8% in hormonal receptor (HR)+/human epidermal growth factor receptor 2 (HER2)−, HR−/Her2+ and HR+/Her2+, respectively; P value

IntroductionThe daily clinical routine in the operating room includes patient positioning. The number of perioperative positioning-related complications is growing, along with the legal proceedings concerning this topic, and only a few guidelines exist to provide specific recommendations. The aim of this survey was to assess perioperative positioning and associated adverse events during gynecological cancer surgery in Germany.MethodsA total of 633 gynecological departments of primary, secondary, and maximum healthcare hospitals in Germany were invited to participate in this multiple-choice online questionnaire. The survey was conducted anonymously for a period of six months. The survey was divided into five different sections: descriptive information about the respondent department, pre- and postoperative management, management of positioning in the operating room based on two fictional case examples, and quality management.ResultsThe response rate of our survey was 29.1 % (184/633). Nearly half of the departments (46.7 %) reported to have had one to five patients with positioning-related complications during the prior 12 months, and 29.1 % had experienced a legal dispute due to positioning-related complications. Departments with more than 50 gynecologic-oncological surgeries per year more often reported positioning-related complications (p=0.003). Standard operating procedures exist in almost every department for laparoscopic (97 %) and open surgery (95.1 %), respectively.DiscussionThe high number of positioning-related complications throughout all departments of different healthcare levels underlines the relevance of this issue and supports the need for a prospective European registry for further analysis. Training and education for all staff members should be routinely implemented to reduce and prevent positioning-related complications.

Peer-to-peer (P2P) energy markets are gaining interest in the energy sector as a means to increase the share of decentralised energy resources (DER), thus fostering a clean, resilient and decentralised supply of energy. Various reports have touted P2P energy markets as ideal use case for blockchain-technology, as it offers advantages such as fault-tolerant operation, trust delegation, immutability, transparency, resilience, and automation. However, relatively little is known about the influence of hardware and communication infrastructure limitations on blockchain systems in real-life applications. In this article, we demonstrate the implementation of a real-world blockchain managed microgrid in Walenstadt, Switzerland. The 37 participating households are equipped with 75 special smart-metres that include single board computers (SBC) that run their own, application-specific private blockchain. Using the field-test setup, we provide an empirical evaluation of the feasibility of a Byzantine fault tolerant blockchain system. Furthermore, we artificially throttle bandwidth between nodes to simulate how the bandwidth of communication infrastructure impacts its performance. We find that communication networks with a bandwidth smaller than 1000 kbit/s – which includes WPAN, LoRa, narrowband IoT, and narrowband PLC – lead to insufficient throughput of the operation of a blockchain-managed microgrid. While larger numbers of validators may provide higher decentralisation and fault-tolerant operation, they considerably reduce throughput. The results from the field-test in the Walenstadt microgrid show that the blockchain running on the smart-metre SBCs can provide a maximum throughput of 10 transactions per second. The blockchain throughput halts almost entirely if the system is run by more than 40 validators. Based on the field test, we provide simplified guidelines for utilities or grid operators interested in implementing local P2P markets based on BFT systems.

Purpose When ipsilateral breast-tumor recurrence (IBTR) following breast-conserving surgery (BCS) occurs, the cure of a potentially life-threatening disease is the main goal. If, however, this is diagnosed early, prognosis is still good and patient-reported outcomes become more important. Despite the fact that many patients would prefer a further BCS, international breast cancer guidelines still recommend mastectomy, mainly because previous radiation implies limited options. Our comparative study evaluates the long-term quality-of-life and outcome in patients with IBTR who received BCS plus intraoperative radiotherapy (IORT) versus mastectomy. Methods Patients with IBTR were retrospectively divided into three groups according to the local treatment: group 1 (n = 26) was treated with BCS + IORT; group 2 (n = 35) received a standard mastectomy; group 3 (n = 52) had a mastectomy with subsequent reconstruction. Outcomes were analyzed after a mean follow-up of 5 years after IBTR. Quality-of-life was evaluated by the validated questionnaire BREAST-Q in 50 patients who fulfilled the inclusion criteria. Results Quality-of-life scores varied within the groups, ranging from 51.4 to 91.3 (out of 100 points). We observed satisfactory scores in all items, with no statistical difference within the groups. Disease-free survival of all groups did not statistically differ, and overall mortality was very low (0.9%). The postinterventional complication rate was lower after BCS (19.2% versus 34.3% after mastectomy and 30.8% after mastectomy with reconstruction). Conclusion For patients with previous surgery and radiation who demand a second BCS in the recurrent situation, this surgical technique can be offered in combination with IORT. Our long-term results imply oncological safety, lower complication rate, and good patient satisfaction.

The caesarean section is one of the most frequently performed surgeries. Due to growing economic challenges, hospitals are encouraged to improve their cost-efficiency. One factor that influences hospital costs of caesarean sections is a prolonged hospital stay.The aim of the current prospective study was to investigate psychosocial factors, with an emphasis on anxiety, and sociodemographic factors that are associated with longer hospital stay after caesarean sections with no medical complications. Data of 195 women who gave birth by caesarean section was analyzed. As possible predictors anxiety levels measured pre-, peri- and postoperative as well as age, parity (primiparous/multiparous), repeated caesarean (yes/no), BMI (30/ ≥30), STAI-Trait scores, duration of surgery, PH arterial and Apgar 5 min. were entered into a backward linear regression with duration of hospital stay as the dependent factor.The analysis revealed that higher age, primiparity as well as higher anxiety scores during the postoperative phase are significant factors associated with prolonged hospital stay. The significant model explains 22.1 % of the variance.The results should sensitize the medical team to these risk factors in order to improve patients' recovery and shorten hospital stays.

Around 30% of births are through caesarean section and repetition rates for receiving a caesarean section are high.The aim of the prospective study was to compare the course of anxiety in women undergoing their first caesarean section and women experiencing a repeated caesarean section.304 women with an indication for an elective caesarean section took part. 155 received their first caesarean section and 149 received a repeated caesarean section.In order to measure the course of anxiety on the day of the caesarean section subjective anxiety levels were measured and saliva samples for cortisol determination were taken at admission, during skin closure and two hours after the surgery. Blood pressure and heart rate were documented at skin incision and skin closure.Women experiencing their first caesarean section displayed significantly higher anxiety levels compared to women with a repeated caesarean section. Scores of the STAI-State and visual analogue scale for anxiety differed significantly at admission (p=.006 and p.001) and heart rate and alpha amylase levels were significantly higher at skin closure (p=.027 and p=.029).The results show that previous experience with a caesarean section has a soothing effect. The study aims to sensitize surgeons, anesthetists, nurses and midwives when treating women receiving a caesarean section and encourage them to incorporate soothing interventions, especially for women receiving their first caesarean section to reduce anxiety levels and consequently improve postoperative recovery and patients' satisfaction.

Background Health care workers (HCW) are heavily exposed to SARS-CoV-2 from the beginning of the pandemic. We aimed to analyze risk factors for SARS-CoV-2 seroconversion among HCW with a special emphasis on the respective healthcare institutions’ recommendation regarding the use of FFP-2 masks. Methods We recruited HCW from 13 health care institutions (HCI) with different mask policies (type IIR surgical face masks vs. FFP-2 masks) in Southeastern Switzerland (canton of Grisons). Sera of participants were analyzed for the presence of SARS-CoV-2 antibodies 6 months apart, after the first and during the second pandemic wave using an electro-chemiluminescence immunoassay (ECLIA, Roche Diagnostics). We captured risk factors for SARS-CoV-2 infection by using an online questionnaire at both time points. The effects of individual COVID-19 exposure, regional incidence and FFP-2 mask policy on the probability of seroconversion were evaluated with univariable and multivariable logistic regression. Results SARS-CoV-2 antibodies were detected in 99 of 2794 (3.5%) HCW at baseline and in 376 of 2315 (16.2%) participants 6 months later. In multivariable analyses the strongest association for seroconversion was exposure to a household member with known COVID-19 (aOR: 19.82, 95% CI 8.11–48.43, p p p = 0.010) and to SARS-CoV-2 infected co-workers (aOR: 2.50, 95% CI 1.52–4.12, p p p = 0.001) were associated with seroconversion. The healthcare institutions’ mask policy (surgical masks during usual exposure vs. general use of FFP-2 masks) did not affect seroconversion rates of HCW during the first and the second pandemic wave. Conclusion Contact with SARS-CoV-2 infected household members was the most important risk factor for seroconversion among HCW. The strongest occupational risk factor was exposure to COVID-19 patients. During this pandemic, with heavy non-occupational exposure to SARS-CoV-2, the mask policy of HCIs did not affect the seroconversion rate of HCWs.

Background The modifications to the standard intensive care unit (ICU) organization that had to be urgently implemented worldwide to overcome the surge of ICU admissions due to patients with a severe coronavirus disease 2019 (COVID-19) have resulted in increased workload and patients-to-nurse ratio. The aim of this study was to investigate whether level of critical care staffing could be associated with an increased risk of ICU mortality (primary endpoint), length of stay, mechanical ventilation and the evolution of disease (secondary study endpoints) in critically ill patients with COVID-19. Methods Retrospective multicenter analysis of the international Risk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry that prospectively enrolls patients developing critical illness due to COVID-19 in several countries worldwide. The analysis was limited to the period between March 1st, 2020 and May 31st, 2020, to ICUs in Switzerland that have collected additional data on nurse and physician staffing. Hierarchical regression models were used to investigate crude and adjusted effects of critical care staffing ratio on study endpoints. We adjusted for diseases severity and weekly caseload. Results Among the 38 Swiss participating ICUs, 17 recorded critical care staffing information. The study population included 437 patients and 2342 daily assessments of patient-to-nurse/physician ratio. Median of daily patient-to-nurse ratio started at 1.0 ([IQR] 0.5–1.5; calendar week 9) and peaked at 2.4 (IQR 0.4-2.0; calendar week 16), while the median of daily patient-to-physician ratio started at 4.0 (IQR 2.1-5.0; calendar week 9) and peaked at 6.8 (IQR 6.3–7.3; calendar week 19). Neither the patient-to-nurse ratio [adjusted Odds Ratio (OR) 1.28, 95% confidence interval (CI) 0.85–1.94; doubling of ratio] nor the patient-to-physician ratio [adjusted OR 1.08, 95% CI 0.87–1.32; doubling of ratio] was associated with ICU mortality. We found no association of critical care staffing on the investigated secondary study endpoints in adjusted models. COnclusion The Swiss health care system successfully overcame the first wave of the COVID-19 pandemic with regards to the unprecedented demand for ICU treatments. The reduced availability of critical care staffing resources per critically ill patient in Swiss ICUs did not translate in an overall increased risk of mortality.

Background: The number of smartphone apps that focus on the prevention, diagnosis, and treatment of depression is increasing. A promising approach to increase the effectiveness of the apps while reducing the individual’s burden is the use of just-in-time adaptive intervention (JITAI) mechanisms. JITAIs are designed to improve the effectiveness of the intervention and reduce the burden on the person using the intervention by providing the right type of support at the right time. The right type of support and the right time are determined by measuring the state of vulnerability and the state of receptivity, respectively. Objective: The aim of this study is to systematically assess the use of JITAI mechanisms in popular apps for individuals with depression. Methods: We systematically searched for apps addressing depression in the Apple App Store and Google Play Store, as well as in curated lists from the Anxiety and Depression Association of America, the United Kingdom National Health Service, and the American Psychological Association in August 2020. The relevant apps were ranked according to the number of reviews (Apple App Store) or downloads (Google Play Store). For each app, 2 authors separately reviewed all publications concerning the app found within scientific databases (PubMed, Cochrane Register of Controlled Trials, PsycINFO, Google Scholar, IEEE Xplore, Web of Science, ACM Portal, and Science Direct), publications cited on the app’s website, information on the app’s website, and the app itself. All types of measurements (eg, open questions, closed questions, and device analytics) found in the apps were recorded and reviewed. Results: None of the 28 reviewed apps used JITAI mechanisms to tailor content to situations, states, or individuals. Of the 28 apps, 3 (11%) did not use any measurements, 20 (71%) exclusively used self-reports that were insufficient to leverage the full potential of the JITAIs, and the 5 (18%) apps using self-reports and passive measurements used them as progress or task indicators only. Although 34% (23/68) of the reviewed publications investigated the effectiveness of the apps and 21% (14/68) investigated their efficacy, no publication mentioned or evaluated JITAI mechanisms. Conclusions: Promising JITAI mechanisms have not yet been translated into mainstream depression apps. Although the wide range of passive measurements available from smartphones were rarely used, self-reported outcomes were used by 71% (20/28) of the apps. However, in both cases, the measured outcomes were not used to tailor content and timing along a state of vulnerability or receptivity. Owing to this lack of tailoring to individual, state, or situation, we argue that the apps cannot be considered JITAIs. The lack of publications investigating whether JITAI mechanisms lead to an increase in the effectiveness or efficacy of the apps highlights the need for further research, especially in real-world apps., Journal of Medical Internet Research, 23 (9), ISSN:1438-8871

We present an experimental and theoretical investigation of the optical diffractive properties of electrically tuneable optical transmission gratings assembled as stacks of periodic slices from a conventional nematic liquid crystal (E7) and a standard photoresist polymer (SU-8). The external electric field causes a twist-type reorientation of the LC molecules toward a perpendicular direction with respect to initial orientation. The associated field-induced modification of the director field is determined numerically and analytically by minimization of the Landau–de Gennes free energy. The optical diffraction properties of the associated periodically modulated structure are calculated numerically on the basis of rigorous coupled-wave analysis (RCWA). A comparison of experimental and theoretical results suggests that polymer slices provoke planar surface anchoring of the LC molecules with the inhomogeneous surface anchoring energy varying in the range 5–20 μJ/m2. The investigated structures provide a versatile approach to fabricating LC-polymer-based electrically tuneable diffractive optical elements (DOEs).

Aim: To non-invasively detect hypoglycemia in individuals with type 1 diabetes (T1D) based on gaze behavior while driving. Methods: Controlled hypoglycemia was induced in 19 individuals (12 males, age 32 ± 7.1 yrs) with T1D (HbA1c 7.1 ± 0.6% [54 ± 6 mmol/mol]) using an adapted hypoglycemic clamp protocol. Gaze and blood glucose (BG) data were gathered while driving in a simulator during three 18 min sessions: session 1 (BG 90-144 mg/dL), session 2 (BG declining from 72 to 45 mg/dL), and session 3 (BG 36-45 mg/dL). A gradient-boosting machine learning (ML) model was built for hypoglycemia (BG Results: Mean venous BG was 105.4 ± 11.4 mg/dL during session 1, declined from 61.4 ± 6.1 mg/dL to 47.2 ± 8.5 mg/dL during session 2, and was 42.7 ± 4.1 mg/dL during session 3, respectively. Gaze analysis provided 29,968 data samples (1,577.5 ± 52 per subject, 10,041 euglycemia, 19,927 hypoglycemia). Overall, ML achieved an area under the receiver-operating-characteristics curve of 0.83 ± 0.09 for hypoglycemia detection with leave-one-subject-out cross-validation. Conclusion: ML-based gaze analysis shows high accuracy in non-invasive hypoglycemia detection while driving. Our approach offers promising potential in various settings where cameras are available. Disclosure V. Lehmann: None. E. Fleisch: Research Support; Self; CSS Health Insurance, Switzerland, Stock/Shareholder; Self; Pathmate-Technologies AG, Switzerland. F. Wortmann: None. C. Stettler: None. M. Maritsch: None. T. Zueger: None. A. Marxer: None. C. Berube: None. M. Kraus: None. C. Albrecht: None. S. Feuerriegel: None. T. Kowatsch: Advisory Panel; Self; Pathmate Technologies AG, Switzerland and Germany, Stock/Shareholder; Self; Pathmate Technologies AG, Switzerland and Germany. Funding Swiss National Science Foundation (SNF CRSII5_183569); Insel Group; Diabetes Center Berne

Background Diet is thought to account for most adult human exposure to per- and polyfluoroalkyl substances (PFAS). Children are particularly vulnerable to adverse health effects of PFAS and may have different eating habits than adults. However, studies of dietary patterns and PFAS in children are limited. Methods We studied 548 Boston-area children with food frequency questionnaire data (89 food items) in early childhood (median age 3.3 years) and plasma concentrations of 6 PFAS quantified in mid-childhood (median age 7.7 years). We used univariate linear regression to examine associations between each food item and PFAS, accounting for multiple comparisons. We next used reduced rank regression (RRR) to estimate overall percent variation in PFAS explained by diet and identify dietary patterns most correlated with PFAS. All models were adjusted for race/ethnicity, maternal education, and household income. Results In univariate analyses, 2-(N-methyl-perfluorooctane sulfonamide) acetate (MeFOSAA) plasma concentrations were 17.8% (95% CI: 7.2, 29.5) and 17.0% (95% CI: 6.4, 28.7) higher per SD increment in intake of ice cream and soda, respectively. RRR identified 6 dietary patterns that together explained 18% variation in the plasma concentrations of the 6 PFAS, of which 50% was explained by a dietary pattern consisting of primarily packaged foods (including ice cream and soda) and fish. Children with higher intake of the packaged foods and fish dietary pattern had higher plasma concentrations of all PFAS, particularly MeFOSAA and PFOS. Conclusions Our analysis examined food intake in association with several PFAS in children and identified dietary determinants that may be sources of PFAS exposure or reflect correlated lifestyle or toxicokinetic factors. Further investigation may help inform measures to modify childhood PFAS exposure.

Just-In-Time Adaptive Intervention (JITAI) is an emerging technique with great potential to support health behavior by providing the right type and amount of support at the right time. A crucial aspect of JITAIs is properly timing the delivery of interventions, to ensure that a user is receptive and ready to process and use the support provided. Some prior works have explored the association of context and some user-specific traits on receptivity, and have built post-study machine-learning models to detect receptivity. For effective intervention delivery, however, a JITAI system needs to make in-the-moment decisions about a user’s receptivity. To this end, we conducted a study in which we deployed machine-learning models to detect receptivity in the natural environment, i.e., in free-living conditions. We leveraged prior work regarding receptivity to JITAIs and deployed a chatbot-based digital coach – Ally – that provided physical-activity interventions and motivated participants to achieve their step goals. We extended the original Ally app to include two types of machine-learning model that used contextual information about a person to predict when a person is receptive: a static model that was built before the study started and remained constant for all participants and an adaptive model that continuously learned the receptivity of individual participants and updated itself as the study progressed. For comparison, we included a control model that sent intervention messages at random times. The app randomly selected a delivery model for each intervention message. We observed that the machine-learning models led up to a 40% improvement in receptivity as compared to the control model. Further, we evaluated the temporal dynamics of the different models and observed that receptivity to messages from the adaptive model increased over the course of the study., Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies, 5 (2), ISSN:2474-9567

BackgroundPer- and polyfluoroalkyl substances (PFAS) are endocrine disrupting chemicals that have been associated with cardiovascular risk factors including elevated body weight and hypercholesterolemia. Therefore, PFAS may contribute to the development of atherosclerosis and cardiovascular disease (CVD). However, no previous study has evaluated associations between PFAS exposure and arterial calcification.Methods and resultsThis study used data from 666 prediabetic adults enrolled in the Diabetes Prevention Program trial who had six PFAS quantified in plasma at baseline and two years after randomization, as well as measurements of coronary artery calcium (CAC) and ascending (AsAC) and descending (DAC) thoracic aortic calcification 13-14years after baseline. We performed multinomial regression to test associations between PFAS and CAC categorized according to Agatston score [low (400)]. We used logistic regression to assess associations between PFAS and presence of AsAC and DAC. We adjusted models for baseline sex, age, BMI, race/ethnicity, cigarette smoking, education, treatment assignment (placebo or lifestyle intervention), and statin use. PFAS concentrations were similar to national means; 53.9% of participants had CAC>11, 7.7% had AsAC, and 42.6% had DAC. Each doubling of the mean sum of plasma concentrations of linear and branched isomers of perfluorooctane sulfonic acid (PFOS) was associated with 1.49-fold greater odds (95% CI: 1.01, 2.21) of severe versus low CAC. This association was driven mainly by the linear (n-PFOS) isomer [1.54 (95% CI: 1.05, 2.25) greater odds of severe versus low CAC]. Each doubling of mean plasma N-ethyl-perfluorooctane sulfonamido acetic acid concentration was associated with greater odds of CAC in a dose-dependent manner [OR=1.26 (95% CI:1.08, 1.47) for moderate CAC and OR=1.37 (95% CI:1.07, 1.74) for severe CAC, compared to low CAC)]. Mean plasma PFOS and n-PFOS were also associated with greater odds of AsAC [OR=1.67 (95% CI:1.10, 2.54) and OR=1.70 (95% CI:1.13, 2.56), respectively], but not DAC. Other PFAS were not associated with outcomes.ConclusionsPrediabetic adults with higher plasma concentrations of select PFAS had higher risk of coronary and thoracic aorta calcification. PFAS exposure may be a risk factor for adverse cardiovascular health among high-risk populations.

As the prevalence of substance use disorders continue to increase nationally and there are more barriers to access traditional illicit drugs, unique ways to create new compounds and mix existing substances will occur. It is critical that consultation-liaison psychiatry and addiction providers appreciate new, potentially dangerous synthetic drugs and combinations of substances that can result in intoxication and withdrawal syndromes along with other concerning medical sequelae. We present a case of a man who peripherally injected bong water with methamphetamine residue and nicotine vaporizer (“vape”) juice as a means of recreational inebriation

As access to a wider variety of illicit substances increases, so do creative mechanisms to utilize substances inside general hospitals among admitted patients. It is important for consultation-liaison psychiatry providers to be aware of the latest routes of administration for these substances. We present a case of a man who rectally inserted crushed opioids mixed with water via a syringe (without a needle), which ultimately contributed to his death. Informally, this is most commonly called “plugging,” “booty bumping,” “hooping,” “boofing,” or “butt rocketing.”

Objective: The aim of this study was to investigate the relationship of BMI with subsequent statural growth among children born in the era of the obesity epidemic.Methods: Among 18,271 children from Belarus (n = 16,781, born 1996 to 1997) and the United States (n = 1,490, born 1999 to 2002), multivariable linear and ordinal logistic regression was used to analyze associations of BMI z score from infancy to adolescence with subsequent standardized length and height velocity, standing height and its components (trunk and leg lengths), and pubertal timing.Results: The prevalence of early adolescent obesity was 6.2% in Belarus and 12.8% in the United States. In both Belarusian and US children, higher BMI z scores in infancy and childhood were associated with faster length and height velocity in early life, while higher BMI z scores during middle childhood were associated with slower length and height velocity during adolescence. Associations with greater standing height and trunk length and earlier pubertal development in adolescence were stronger for BMI z scores at middle childhood than BMI z scores at birth or infancy.Conclusions: These findings in both Belarus and the United States support the role of higher BMI in accelerating linear growth in early life (taller stature and longer trunk length) but earlier pubertal development and slower linear growth during adolescence.

The Internet of Things (IoT) promises to deliver tremendous business value and disrupt various industries. However, many companies are taking much longer than anticipated to realize these opportunities. To exploit the digital data streams flowing from their smart, connected products (IoT field data), companies need to identify new opportunities that go beyond well-known product and service innovations. We describe how manufacturing companies are leveraging IoT field data to innovate in their internal processes at all stages of the product lifecycle.

Exposure to per- and polyfluoroalkyl substances (PFASs) may interfere with lipid regulation. However, most previous studies were cross-sectional with the risk of reverse causation, suggesting a need for long-term prospective studies. We examined the relationship of baseline plasma PFAS concentrations with repeated measures of blood lipids. We included 888 prediabetic adults from the Diabetes Prevention Program (DPP) and DPP Outcomes Study, who had measurements of 6 plasma PFAS concentrations at baseline (1996–1999) and repeated measures of blood lipids over 15 years of follow-up, and were initially randomized to placebo or a lifestyle intervention. We used linear regression to examine cross-sectional associations of PFAS concentrations and lipid levels at baseline, and evaluated prospective risks of hypercholesterolemia and hypertriglyceridemia using Cox proportional hazard models, and tested for effect modification by study arm. Participants (65.9% female, 57.0% White, 65.9% aged 40–59 years) had comparable PFAS concentrations [e.g., median (IQR) perfluorooctanoic acid (PFOA) 4.9 ng/mL (3.2)] with the general U.S. population in 1999–2000. We observed higher total cholesterol at baseline per doubling of PFOA (β: 6.1 mg/dL, 95% CI: 3.1, 9.04), perfluorohexane sulfonic acid (PFHxS, β: 2.2 mg/dL, 95% CI: 0.2, 4.3), and perfluorononanoic acid (PFNA, β: 2.9 mg/dL, 95% CI: 0.7, 5.0). Prospectively, baseline concentrations of several PFASs, including PFOA, PFOS, PFHxS and PFNA, predicted higher risks of incident hypercholesterolemia and hypertriglyceridemia, but only in the placebo group and not the lifestyle intervention group. For example, participants in the placebo group with PFOA concentration > median (4.9 ng/mL) were almost twice as likely (HR: 1.90, 95% CI: 1.25, 2.88) to develop hypertriglyceridemia compared to those ≤median. Findings suggest adverse effects of some PFASs on lipid profiles in prediabetic adults. However, the detrimental effect was attenuated with a lifestyle intervention. Keywords: Lipid and cholesterol, Hyperlipidemia, Per- and polyfluoroalkyl substances, Environmental epidemiology, Lifestyle intervention, Prospective assessment

OBJECTIVE Perfluoroalkyl and polyfluoroalkyl substances (PFASs) are suspected endocrine disruptors widely detected across populations. We examine the extent to which PFASs are associated with diabetes incidence and microvascular disease. Secondarily, we tested whether a lifestyle intervention modifies associations and decreases concentrations. RESEARCH DESIGN AND METHODS We analyzed data from a prospective cohort of 957 participants from the Diabetes Prevention Program (DPP) trial and Diabetes Prevention Program Outcomes Study (DPPOS). At baseline, participants were randomized to an intensive lifestyle intervention of diet, physical activity, and behavior modification or a placebo medication. We quantified plasma concentrations of six PFASs at baseline and 2 years after randomization. Participants were monitored for ∼15 years, repeatedly tested for diabetes, and evaluated for microvascular disease at the end of the follow-up. RESULTS A doubling in baseline branched perfluorooctanoic acid concentration was associated with a 14% increase in diabetes risk for the placebo (hazard ratio [HR] 1.14, 95% CI 1.04, 1.25) but not in the lifestyle intervention group (HR 1.01, 95% CI 0.92, 1.11, Pinteraction = 0.11). Mean change in plasma baseline branched perfluorooctanoic acid concentration was greater for the placebo (0.96 ng/mL; 95% CI 0.71, 1.22) compared with the lifestyle intervention group (0.31 ng/mL; 95% CI 0.14, 0.48) 2 years after randomization. Each doubling in N-ethyl-perfluorooctane sulfonamido acetic acid was associated with 17% greater odds of prevalent microvascular disease (OR 1.17, 95% CI 1.05, 1.31), and a similar association was observed for perfluorodimethylhexane sulfonic acid (OR 1.18, 95% CI 1.04, 1.35), regardless of treatment. CONCLUSIONS Some plasma PFASs were associated with diabetes and microvascular disease. Our results suggest that exercise and diet may attenuate the diabetogenic association of PFASs.

Triple negative breast cancer (TNBC) harbors a heterogeneous group of carcinomas with poor prognosis and high genetic variability. As a potential aim for targeted therapy, genetic mutations leading to an activation of the phosphoinositide 3-kinase pathway in a catalytic subunit (PIK3CA) in breast cancer have been analyzed currently. Little is known about the clinical impact and prognostic or predictive value of this marker in TNBC subtypes. Samples from 119 TNBC cases were submitted to immunohistochemical PIK3CA protein expression analysis and scored semi-quantitatively as negative, weak (1 +), or strongly expressed (2 +). Expression scores were correlated to patient’s characteristics, imaging features, and TNBC subtypes. TNBC subtypes were categorized into four subtypes: basal like, mesenchymal like, luminal androgen receptor (LAR), and immunomodulatory. We did not observe differences in clinical aspects and imaging features between TNBC with and without PIK3CA expression. PIK3CA expression was in general higher in the LAR subtype. The disease-free survival and overall survival were significantly better in TNBC with PIK3CA protein expression, independent of TNBC subtypes. Despite conflicting results in the literature, our study clearly shows a better outcome of PIK3CA-expressing TNBC, independent of TNBC subtypes. PIK3CA expression in TNBC is not associated with specific clinical or diagnostic features. Further molecular studies and meta-analysis are warranted to clarify the prognostic and predictive role of PIK3CA protein expression.

We demonstrate that two-photon polymerisation-based direct laser writing (TPP-DLW) is a very convenient technique for the fabrication of tunable liquid crystal (LC) based optical diffractive structures. The underlying TPP-DLW scaffold is composed of out-of-plane oriented polymeric ribbons with surface relief gratings on their side walls that induce parallel alignment of the adjacent LC medium. With the aid of such scaffolds infiltrated with the standard nematic liquid crystalline mixture E7, we prepared optical transmission gratings whose diffraction efficiency can be tuned with electric or magnetic fields. We report on an experimental and theoretical comparison between both types of tuning mechanisms.

Despite the fact that semi-autonomous vehicles will become more and more prevalent in the coming decades, recent studies have highlighted that traffic accidents will persist as a core issue for road users, insurers, and policy makers alike. Researchers and industry players see potential in the technology embedded in semi-autonomous vehicles to combat this challenge by reliably predicting locations with a high likelihood of traffic accidents. This technology can be leveraged to detect accidents and ‘near miss incidents’, such as heavy braking and evasive manoeuvres, otherwise known as Critical Driving Events (CDEs). The locations of CDEs could identify areas of high accident exposure, offering automotive insurers a unique opportunity to reduce traffic accidents through the adoption of active loss prevention business models, such as providing safe-routing services and in-vehicle warnings. To date, there is limited empirical evidence on whether the Crash Frequency and Crash Rate of locations can be accurately identified through CDEs. To address this research gap, an 18-week naturalistic driving field study of 72 vehicles was conducted in Switzerland, covering over 690,000 km. Data collected from the CAN Bus of these vehicles indicate that there is a proportional relationship between the CDEs of the fleet, and the Crash Frequency and Crash Rate of a location. Furthermore, a nationwide spatial regression analysis was applied to determine Crash Frequency across the majority of the Swiss road network. We identify the relationship between Crash Frequency, and the CDEs and Trip Frequency of the fleet, along with additional explanatory variables for urban and highway locations. These insights provide first evidence that insurance companies and other industry players with access to a nationwide semi-autonomous fleet can determine existing and emerging locations of high accident probability, enabling more proactive business models and safety focused services.

Objective: To determine whether prenatal sex hormones from maternal saliva are associated with birth weight-for-gestational age. Study Design: We measured salivary progesterone, testosterone, estradiol, dehydroepiandrosterone (DHEA) and cortisone in 504 pregnant women in a Mexico City cohort in the. We performed linear and modified Poisson regression to examine associations of log-transformed hormones with birth weight-for-gestational age z-scores and the risk of small-for-gestational age (SGA) and large-for-gestational age (LGA) adjusting for maternal age, sex, BMI, parity, smoking, education and socioeconomic status. Results: 15% of infants were SGA and 2% were LGA. Each interquartile range increment in testosterone/estradiol ratio was associated with a 0.12 decrement in birth weight-for-gestational age z-score (95% CI: −0.27, −0.02) and a 50% higher risk of SGA versus appropriate-for-gestational age (AGA) (95% CI: 1.13, 1.99). Conclusion: Higher salivary testosterone/estradiol ratios may affect fetal growth, and identifying the predictors of hormone levels may be important to optimizing fetal growth.

In developed countries, around 25% of all births involve labour induction. Studies have indicated that labour induction negatively influences the birth experience as well as the birth process. However, the impact of labour induction when only considering vaginal deliveries has not been studied yet, which was the purpose of the present study. 186 women who gave birth vaginally took part in this prospective study. 95 women gave birth after spontaneous onset of labour (SL-group) and 91 women received a labour induction (LI-group). Eight to 72 h after birth, the women filled in the revised version of the standardised Childbirth Experience Questionnaire, which examines the birth experience in four dimensions (Own Capacity, Perceived Safety, Participation and Professional Support). Medical details regarding birth and fetal outcomes were taken from the medical records. Birth outcomes (the number of epidural anaesthesia, the duration of birth, birth risks and childbirth injuries) as well as fetal outcomes (APGAR after 1 and 5 min and arterial cord pH) did not differ between the groups. Regarding the subjective birth experience, the LI-group indicated significantly lower values for Perceived Safety and Participation compared to the SL-group, while there were no differences for the dimensions Own Capacity and Professional Support. Successful labour induction resulting in a vaginal birth did not negatively influence birth and fetal outcomes and only partly affected the women’s birth experience. The negative impact of labour induction on the dimensions Perceived Safety and Participation should sensitize midwives in order to provide optimal support.

Structured pedagogic programmes are emerging as a promising approach to address low learning outcomes in developing countries. The delivery model of these programmes matters, and on-site instructional coaching has been shown to be a key component. In this article, we report on a series of government-led randomised experiments in South African primary schools, which evaluates the efficacy of different aspects of instructional coaching as part of structured learning programmes. In the first multi-year on-site coaching study, we found that the structured pedagogic programme combined with coaching was substantially more cost-effective than the structured pedagogic programme that used conventional centralised teacher training. The ability to scale up on-site coaching, however, is an open question. In the current experiment, a virtual coaching model that includes provision of a tablet with additional electronic resources was tested. The article reports on the midline evaluation results, which show that after one year of intervention, virtual coaching was no less effective than on-site coaching at improving both the instructional practice of teachers and the targeted literacy outcomes. This points to the potential for technological innovations to enable wider rollout of coaching programmes, even in contexts where teachers are not familiar with new technologies.

We experimentally compare two modes of in-service professional development for South African public primary school teachers. In both modes teachers received the same learning materials and daily lesson plans, aligned to the official literacy curriculum. Students exposed to two years of the program improved their reading proficiency by 0.12 standard deviations if their teachers received centralized training, compared to 0.24 if their teachers received in-class coaching. Classroom observations reveal that teachers were more likely to split students into smaller reading groups, which enabled individualized attention and more opportunities to practice reading. Results vary by class size and baseline student reading proficiency. [ABSTRACT FROM AUTHOR]

Homeless persons die significantly younger than their housed counterparts. In many cases, relatively straightforward primary care issues escalate into life-threatening, expensive emergencies. Poor health outcomes driven by negative interactions between comorbid symptoms meet the definition of a health syndemic in this population. Successful primary care of patients struggling with homelessness may result in long-term lifesaving measures along with decreased expenditure to hospital systems. This primary prevention requires patience, creativity, and acknowledgment that the source of many confounders may lay outside the control of these patients.

An ever growing variety of smart, connected Internet of Things (IoT) devices poses completely new challenges for businesses regarding security and privacy. In fact, the adoption of smart products may depend on the ability of organizations to offer systems that ensure adequate sensor data integrity while guaranteeing sufficient user privacy. In light of these challenges, previous research indicates that blockchain technology could be a promising means to mitigate issues of data security arising in the IoT. Building upon the existing body of knowledge, we propose a design theory, including requirements, design principles, and features, for a blockchain-based sensor data protection system (SDPS) that leverages data certification. To support this, we designed and developed an instantiation of an SDPS (CertifiCar) in three iterative cycles intented to prevent the fraudulent manipulation of car mileage data. Following the explication of our SDPS, we provide an ex post evaluation of our design theory considering CertifiCar and two additional use cases in the areas of pharmaceutical supply chains and energy microgrids. Our results suggest that the proposed design ensures the tamper-resistant gathering, processing, and exchange of IoT sensor data in a privacy-preserving, scalable, and efficient manner.

CONTEXT There are limited data on the nature of environmental lead hazards identified during residential inspections for child blood lead levels (BLLs) of less than 10 μg/dL. We compare inspection findings for child BLLs of 5 to 9 μg/dL versus 10 μg/dL or more. DESIGN We reviewed inspection reports in Maine from September 2016 to March 2018. We used continuity-adjusted or Fisher's exact test for categorical variables and Wilcoxon rank-sum tests for continuous variables to compare differences in child, family, household, and lead hazard characteristics between BLL categories (5-9 μg/dL vs ≥10 μg/dL). We used Spearman correlation coefficients to assess relationships between home surface lead dust measurements and BLLs. RESULTS Of 351 residential inspections, 272 (77%) were for children with BLLs of 5 to 9 μg/dL. Children with BLLs of 5 to 9 μg/dL as compared with children with BLLs of 10 μg/dL or more were less likely to chew window sills and door frames (8% vs 21%; P = .01), but otherwise were similar with respect to other established risk factors for lead poisoning. Children with BLLs of 5 to 9 μg/dL tended to have fewer paint hazards inside their homes (64% vs 78%; P = .03), and they were more likely to have dust-only hazards (8% vs 3%) or no identified lead paint hazards (23% vs 15%), though these differences were not statistically significant. For children with BLLs of 5 to 9 μg/dL, BLL was weakly correlated with average window sill dust level (Spearman r = 0.16; P = .01) and average floor dust level (r = 0.13; P = .03), but these correlations were not observed for children with BLLs of 10 μg/dL and higher. CONCLUSIONS We have found that inspections of homes of children with BLLs of 5 to 9 μg/dL are nearly as likely to identify lead hazards that require abatement as inspections of homes of children with BLLs of 10 μg/dL.