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The Keck Planet Imager and Characterizer (KPIC) is a series of upgrades for the Keck II Adaptive Optics (AO) system and the NIRSPEC spectrograph to enable diffraction-limited, high-resolution ($R>30,000$) spectroscopy of exoplanets and low-mass companions in the K and L bands. Phase I consisted of single-mode fiber injection/extraction units (FIU/FEU) used in conjunction with an H-band pyramid wavefront sensor. Phase II, deployed and commissioned in 2022, adds a 1000-actuator deformable mirror, beam-shaping optics, a vortex coronagraph, and other upgrades to the FIU/FEU. The use of single-mode fibers provides a gain in stellar rejection, a substantial reduction in sky background, and an extremely stable line-spread function on the spectrograph. In this paper we present the results of extensive system-level laboratory testing and characterization showing the instrument's Phase II throughput, stability, repeatability, and other key performance metrics prior to delivery and during installation at Keck. We also demonstrate the capabilities of the various observing modes enabled by the new system modules using internal test light sources. Finally, we show preliminary results of on-sky tests performed in the first few months of Phase II commissioning along with the next steps for the instrument. Once commissioning of Phase II is complete, KPIC will continue to characterize exoplanets at an unprecedented spectral resolution, thereby growing its already successful track record of 23 detected exoplanets and brown dwarfs from Phase I. Using the new vortex fiber nulling (VFN) mode, Phase II will also be able to search for exoplanets at small angular separations less than 45 milliarcseconds which conventional coronagraphs cannot reach., 13 pages; 6 figures; to appear in Proceedings of the SPIE, Ground-based and Airborne Instrumentation for Astronomy IX, Vol. 12184

Frailty is associated with adverse outcomes in heart failure (HF). A parsimonious frailty index (FI) that predicts outcomes of older, multimorbid patients with HF could be a useful resource for clinicians. A retrospective study of veterans hospitalized from October 2015 to October 2018 with HF, aged ≥50 years, and discharged home developed a 10-item parsimonious FI using machine learning from diagnostic codes, laboratory results, vital signs, and ejection fraction (EF) from outpatient encounters. An unsupervised clustering technique identified 5 FI strata: severely frail, moderately frail, mildly frail, prefrail, and robust. We report hazard ratios (HRs) of mortality, adjusting for age, gender, race, and EF and odds ratios (ORs) for 30-day and 1-year emergency department visits and all-cause hospitalizations after discharge. We identified 37,431 veterans (age, 73 ± 10 years; co-morbidity index, 5 ± 3; 43.5% with EF ≤40%). All frailty groups had a higher mortality than the robust group: severely frail (HR 2.63, 95% confidence interval [CI] 2.42 to 2.86), moderately frail (HR 2.04, 95% CI 1.87 to 2.22), mildly frail (HR 1.60, 95% CI 1.47 to 1.74), and prefrail (HR 1.18, 95% CI: 1.07 to 1.29). The associations between frailty and mortality remained unchanged in the stratified analysis by age or EF. The combined (severely, moderately, and mildly) frail group had higher odds of 30-day emergency visits (OR 1.62, 95% CI 1.43 to 1.83), all-cause readmission (OR, 1.75, 95% CI 1.52 to 2.02), 1-year emergency visits (OR 1.70, 95% CI 1.53 to 1.89), rehospitalization (OR 2.18, 95% CI 1.97 to 2.41) than the robust group. In conclusion, a 10-item FI is associated with postdischarge outcomes among patients discharged home after a hospitalization for HF. A parsimonious FI may aid clinical prediction at the point of care.

Direct imaging studies have mainly used low-resolution spectroscopy ($R\sim20-100$) to study the atmospheres of giant exoplanets and brown dwarf companions, but the presence of clouds has often led to degeneracies in the retrieved atmospheric abundances (e.g. C/O, metallicity). This precludes clear insights into the formation mechanisms of these companions. The Keck Planet Imager and Characterizer (KPIC) uses adaptive optics and single-mode fibers to transport light into NIRSPEC ($R\sim35,000$ in $K$ band), and aims to address these challenges with high-resolution spectroscopy. Using an atmospheric retrieval framework based on petitRADTRANS, we analyze KPIC high-resolution spectrum ($2.29-2.49~\mu$m) and archival low-resolution spectrum ($1-2.2~\mu$m) of the benchmark brown dwarf HD 4747 B ($m=67.2\pm1.8~M_{\rm{Jup}}$, $a=10.0\pm0.2$ au, $T_{\rm eff}\approx1400$ K). We find that our measured C/O and metallicity for the companion from the KPIC high-resolution spectrum agree with that of its host star within $1-2\sigma$. The retrieved parameters from the $K$ band high-resolution spectrum are also independent of our choice of cloud model. In contrast, the retrieved parameters from the low-resolution spectrum are highly sensitive to our chosen cloud model. Finally, we detect CO, H$_2$O, and CH$_4$ (volume mixing ratio of log(CH$_4$)=$-4.82\pm0.23$) in this L/T transition companion with the KPIC data. The relative molecular abundances allow us to constrain the degree of chemical disequilibrium in the atmosphere of HD 4747 B, and infer a vertical diffusion coefficient that is at the upper limit predicted from mixing length theory., Comment: 33 pages, 16 figures, Accepted to ApJ

Tidal marshes and mangroves are increasingly valued for nature-based mitigation of coastal storm impacts, such as flooding and shoreline erosion hazards, which are growing due to global change. As this review highlights, however, hazard mitigation by tidal wetlands is limited to certain conditions, and not all hazards are equally reduced. Tidal wetlands are effective in attenuating short-period storm-induced waves, but long-period storm surges, which elevate sea levels up to several meters for up to more than a day, are attenuated less effectively, or in some cases not at all, depending on storm conditions, wetland properties, and larger-scale coastal landscape geometry. Wetlands often limit erosion, but storm damage to vegetation (especially mangrove trees) can be substantial, and recovery may take several years. Longer-term wetland persistence can be compromised when combined with other stressors, such as climate change and human disturbances. Due to these uncertainties, nature-based coastal defense projects need to adopt adaptive management strategies. Expected final online publication date for the

Introduction In the early 2000s when Tactical Combat Casualty Care was developed, the adoption of prophylactic antibiotic use was not mainstream. Back then, guidelines were derivative of civilian trauma guidelines which did not include widespread prophylactic antibiotic use. Current protocols across the DoD have embraced the use of prophylactic antibiotic use before reaching a military treatment facility as evidenced by Tactical Combat Casualty Care guidelines and several Joint Trauma System Clinical Practice Guidelines. This review intends to find trends associated with the use of antibiotics in the military setting and answer the research question: Do current Army doctrine and practices address these issues and how can they be reworked to address them if needed? Materials and Methods Methods were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary author utilized four databases to locate articles: MEDLINE (EBSCOhost), Cochrane Central Register of Controlled Trials (Wiley), CINAHL Complete (EBSCOhost), and Embase (Elsevier). The following keywords were utilized: “Combat casualty,” “antibiotic,” “trauma,” and “prehospital.” This ultimately led to 19 articles included in the review. Results Nineteen articles were included in the final review and placed into one of the following categories: Overall antibiotic use, guideline adherence and practices, strains, and infection risk factors. Overall, the Army Health System has shown that there is room for improvement in terms of antibiotic stewardship and training regarding antibiotics. Conclusion Infectious diseases pose a substantial risk to combat wounded. The Army Health System must anticipate encountering challenges with delivering care to patients suffering infections in addition to serious combat injuries. A systematic review of the literature highlights several areas for improvement, primarily areas involving pathogen surveillance, treatment of pediatric populations, and the Army’s operational domain of training.

Bombay phenotype, an exceptionally rare blood type in individuals outside of Southeast Asia, occurs in approximately 1 in 1,000,000 individuals in Europe. This blood phenotype is characterized by the absence of the H antigen on red blood cells (RBCs) and in secretions. As the H antigen is the structure on which the ABO system is built, individuals lacking this antigen are unable to produce A or B antigens and appear as type O on routine ABO phenotyping. H deficiency does not cause ill effect; however, these individuals produce an anti-H alloantibody capable of causing severe acute hemolytic transfusion reactions when exposed to RBCs that express the H antigen. In this case study, we highlight the incidental discovery of a patient with Bombay phenotype in a North American hospital system, expected test results, the immunologic and genetic basis underlying the Bombay and para-Bombay phenotypes, and methods to ensure availability of compatible blood.

Grounded in communicated narrative sense-making theory (CNSM), this study explored how women who were pregnant during the COVID-19 pandemic (n = 21) communicatively made sense of their experience in light of their received social support. Interview data were inductively analyzed for emergent themes and deductively analyzed for type of social support and narrative tone. Findings uncovered themes of a) connecting to mitigate stress, b) drawing on others' knowledge, c) receiving socially distant instrumental support, and d) lacking medical professional support. Further, instances of informational, instrumental, and/or emotional support frequently occurred in stories with a positive narrative tone, whereas instances of insufficient support frequently appeared in stories with a negative tone. These results support previous research on the benefits and barriers of social support during pregnancy and extend theorizing about the implications of interpersonal interactions on CNSM. Practical applications are explored for medical professionals endeavoring to support pregnant women during a pandemic.

Although miscarriage is commonly considered a “women’s issue,” pregnancy loss often occurs in opposite-sex marriages and affects the well-being of both spouses. The present study investigated how c...

Open adoption relationships are rife with privacy dilemmas and fuzzy boundaries, which require ongoing coordination of private disclosures as a result. The present study employed communication privacy management (CPM) theory to examine adoptive parents’ ( N = 354) private disclosures with the birth family across in-person and mediated (i.e., texting and social media) contexts. SEM analysis revealed that adoptive families who were more private and were concerned about the birth family sharing private information with others viewed disclosures to the birth family as risky. These privacy concerns related to adoptive parents being more clear with the birth family about preferences for sharing that private information with others. More social media contact between birth and adoptive parents predicted increased perceptions of risk of disclosure to birth parents. Results advance CPM theorizing by underscoring the motivational bases of perceived risk, the importance of anticipated boundary turbulence, and the nuanced privacy management processes within communication modes.

This paper critically engages with dynamics of the Chinese food safety governance infrastructure following the melamine crisis. It presents a qualitative analysis of sixteen in-depth stakeholder interviews in Hunan, Hubei and Henan. We reveal tensions between a segmented model of governance and a centralised model, between a centralised top-down model and stakeholder participation, and between a public model and a private, decentral market where corporate reputation must result in transparency and trust. Stakeholders also see gaps between ideals of inclusive, transparent and participatory governance, and effective problem-solving. Governance of food safety in China, even when targeting inclusion and public accountability, remains heavily dependent on the central state as a pivotal actor.

Presented herein is an approach for correlating active pharmaceutical ingredient (API) bulk properties such as particle size, surface area, powder flow, morphology, and dissolution in order to prov...

Objective This study aimed to determine the medical cost impact and return on investment (ROI) of a large, commercial, digital, weight-management intensive lifestyle intervention (ILI) program (Real Appeal). Methods Participants in this program were compared with a control group matched by age, sex, geographic region, health risk, baseline medical costs, and chronic conditions. Medical costs were defined as the total amount paid for all medical expenses, inclusive of both the insurers' and the study participants' responsibility. Results In the 3 years following program registration, the intent-to-treat (ITT) cohort had significantly lower medical expenditures than the matched controls, with an average of -$771 or 12% lower costs (P = 0.002). Among 4,790 ITT participants, a total savings of $3,693,090 compared with total program costs of $1,639,961 translated into a 2.3:1 ROI. Program completers (n = 3,990), who attended more sessions than the overall ITT group, had greater mean weight loss (-4.4%), greater cost savings (-$956 or 14%), and an ROI of 2.0:1 over the 3-year time frame compared with matched controls. Conclusions The findings demonstrated that the digital weight-management ILI was associated with a significantly positive ROI. Employers and payers willing to cover the cost of an ILI that produces both weight loss and demonstrated cost benefits can improve health and save money for their population with overweight or obesity.

Burkholderia pseudomallei, the causative agent of the disease melioidosis, has been isolated from the environment in 45 countries. The treatment of melioidosis is complex, requiring lengthy antibiotic regimens, which can result in the relapse of the disease following treatment cessation. It is important that novel therapies to treat infections with B. pseudomallei be assessed in appropriate animal models, and discussions regarding the different protocols used between laboratories are critical. A ‘deep dive’ was held in October 2020 focusing on the use of the BALB/c mouse model and the inhalational route of infection to evaluate new antibiotic therapies.

Infant protection is an important but largely neglected aspect of parental care. Available theory and research suggest that endocrine levels and neural responses might be biological correlates of protective behavior. However, no research to date examined associations between these neurobiological and behavioral aspects. This study, preregistered on https://osf.io/2acxd, explored the psychobiology of paternal protection in 77 new fathers by combining neural responses to infant-threatening situations, self-reported protective behavior, behavioral observations in a newly developed experimental set-up (Auditory Startling Task), and measurements of testosterone and vasopressin. fMRI analyses validated the role of several brain networks in the processing of infant-threatening situations and indicated replicable findings with the infant-threat paradigm. We found little overlap between observed and reported protective behavior. Robust associations between endocrine levels, neural responses, and paternal protective behavior were absent. ispartof: Developmental Psychobiology vol:63 issue:5 pages:1358-1369 ispartof: location:United States status: published

Malnutrition is associated with worse prognosis and increased risk for adverse outcomes in patients hospitalized with heart failure (HF). The objective is to assess the utility of adding the Prognostic Nutritional Index (PNI), a validated measure of nutritional status, to the Veterans Health Administration frailty index (VA-FI) in predicting time to death in patients hospitalized with HF. We conducted a retrospective cohort study of veterans age ≥50 years hospitalized with HF as their primary diagnosis. PNI was calculated using lab values in the year prior to hospitalization with the following equation: 10 x serum albumin (g/dL)+0.005 x total lymphocyte count (mm3). VA-FI identified five groups: robust (≤0.1), prefrail (0.1–0.2), frail (0.2–0.3), moderately frail (0.3–0.4), and severely frail (>0.4). PNI was added to VA-FI (VA-FI-Nutrition) using the same cutoffs. We identified changes in frailty status using VA-FI versus VA-FI-Nutrition by summarizing the count by each class and reported the hazard ratio (HR) for all-cause mortality in each VA-FI category based on the new VA-FI-Nutrition groups. VA-FI-Nutrition identified patients within each VA-FI class that belong to the next frailty strata: robust (20.2%), prefrail (18.3%), frail (16.7%) and moderately frail (16.7%). We observed higher mortality rates among those whose frailty class changed based on VA-FI-Nutrition compared to VA-FI: robust (HR, 1.65, 95%CI:1.38, 1.97), prefrail (HR, 1.52, 95%CI: 1.41, 1.65), frail (HR, 1.42, 95%CI: 1.33, 1.52), and moderately frail (HR, 1.33, 95%CI: 1.24, 1.43). Adding PNI to VA-FI provides a more accurate mortality assessment and may be utilized to triage high-risk patients.

Objectives Cycling is an important means of transportation in the Netherlands. Unfortunately, the number of cycling accidents and their adverse outcomes (injury and death) are on the rise. We set out to observe the nature of these accidents in Maastricht from 2001 to 2015 and analyzed the recommendations of stakeholders on ways to improve cycling safety. Methods An explanatory sequential mixed methodology was used for this population-based study. In the first phase, a retrospective quantitative analysis of the VIA (R) accident database for Maastricht was done. This was followed by a thematic analysis of data from five semi-structured interviews. Integration was at the Interpretation stage. Result The first phase showed males (54%) and under-25s (59.9%) had the most cycling accidents, while a larger percentage of females (50.7%) and people >65 years (67%) had adverse outcomes with accidents. More accidents occurred at intersections (52.6%), on shared roads (61.4%), and involved motorized vehicles (95.6%). Bivariate analysis and multivariable logistic regression showed that cycling accidents involving elderly people, women, wet weather or road surfaces, an innocent cyclist, the northeastern district, and morning hours had a higher chance of injury or death. Thematic analysis summarised stakeholder opinions under four themes: role in cycling safety; partners of cycling safety; the importance of accurate data; and investing in safety. Most of the respondents felt improvements in the city's accident database, cycling policy, and infrastructure were needed. Conclusion Our findings suggest that there has been a decrease in the overall number of cycling accidents in the 15-year period studied. However, differences in sociodemographic variables still determine the distribution and severity of accidents in Maastricht. The existing cycling database at the time of the study needed improvements with data collection and the city needs to involve more stakeholders in its policy-making process.

Inflammation, including reactive oxygen species and inflammatory cytokines in tissues amplify various post-translational modifications of self-proteins. A number of post-translational modifications have been identified as autoimmune biomarkers in the initiation and progression of Type 1 diabetes. Here we show the citrullination of pancreatic glucokinase as a result of inflammation, triggering autoimmunity and affecting glucokinase biological functions. Glucokinase is expressed in hepatocytes to regulate glycogen synthesis, and in pancreatic beta cells as a glucose sensor to initiate glycolysis and insulin signaling. We identify autoantibodies and autoreactive CD4+ T cells to glucokinase epitopes in the circulation of Type 1 diabetes patients and NOD mice. Finally, citrullination alters glucokinase biologic activity and suppresses glucose-stimulated insulin secretion. Our study define glucokinase as a Type 1 diabetes biomarker, providing new insights of how inflammation drives post-translational modifications to create both neoautoantigens and affect beta cell metabolism. ispartof: NATURE COMMUNICATIONS vol:13 issue:1 ispartof: location:England status: published