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ContextDuring puberty, reactivation of the reproductive axis occurs during sleep, with LH pulses specifically tied to deep sleep. This association suggests that deep sleep may stimulate LH secretion, but there have been no interventional studies to determine the characteristics of deep sleep required for LH pulse initiation.ObjectiveThe objective of this study was to determine the effect of deep sleep fragmentation on LH secretion in pubertal children.Design and settingStudies were performed in a clinical research center.SubjectsFourteen healthy pubertal children (11.3-14.1 y) participated in the study.InterventionsSubjects were randomized to two overnight studies with polysomnography and frequent blood sampling, with or without deep sleep disruption via auditory stimuli.ResultsAn average of 68.1 ±10.7 (± SE) auditory stimuli were delivered to interrupt deep sleep during the disruption night, limiting deep sleep to only brief episodes (average length disrupted 1.3 ± 0.2 min vs normal 7.1 ± 0.8 min, P < .001), and increasing the number of transitions between non-rapid eye movement (NREM), REM, and wake (disrupted 274.5 ± 33.4 vs normal 131.2 ± 8.1, P = .001). There were no differences in mean LH (normal: 3.2 ± 0.4 vs disrupted: 3.2 ± 0.5 IU/L), LH pulse frequency (0.6 ± 0.06 vs 0.6 ± 0.07 pulses/h), or LH pulse amplitude (2.8 ± 0.4 vs 2.8 ± 0.4 IU/L) between the two nights. Poisson process modeling demonstrated that the accumulation of deep sleep in the 20 minutes before an LH pulse, whether consolidated or fragmented, was a significant predictor of LH pulse onset (P < .001).ConclusionIn pubertal children, nocturnal LH augmentation and pulse patterning are resistant to deep sleep fragmentation. These data suggest that, even when fragmented, deep sleep is strongly related to activation of the GnRH pulse generator.

Oxygen therapy is known to reduce loop gain (LG) in patients with obstructive sleep apnoea (OSA), yet its effects on the other traits responsible for OSA remain unknown. Therefore, we assessed how hyperoxia and hypoxia alter four physiological traits in OSA patients. Eleven OSA subjects underwent a night of polysomnography during which the physiological traits were measured using multiple 3-min 'drops' from therapeutic continuous positive airway pressure (CPAP) levels. LG was defined as the ratio of the ventilatory overshoot to the preceding reduction in ventilation. Pharyngeal collapsibility was quantified as the ventilation at CPAP of 0 cmH 2 O. Upper airway responsiveness was defined as the ratio of the increase in ventilation to the increase in ventilatory drive across the drop. Arousal threshold was estimated as the level of ventilatory drive associated with arousal. On separate nights, subjects were submitted to hyperoxia (n = 9; F iO2 ∼0.5) or hypoxia (n = 10; F iO2 ∼0.15) and the four traits were reassessed. Hyperoxia lowered LG from a median of 3.4 [interquartile range (IQR): 2.6-4.1] to 2.1 (IQR: 1.3-2.5) (P < 0.01), but did not alter the remaining traits. By contrast, hypoxia increased LG [median: 3.3 (IQR: 2.3-4.0) vs. 6.4 (IQR: 4.5-9.7); P < 0.005]. Hypoxia additionally increased the arousal threshold (mean ± s.d. 10.9 ± 2.1 l min -1 vs. 13.3 ± 4.3 l min -1 ; P < 0.05) and improved pharyngeal collapsibility (mean ± s.d. 3.4 ± 1.4 l min -1 vs. 4.9 ± 1.3 l min -1 ; P < 0.05), but did not alter upper airway responsiveness (P = 0.7). This study demonstrates that the beneficial effect of hyperoxia on the severity of OSA is primarily based on its ability to reduce LG. The effects of hypoxia described above may explain the disappearance of OSA and the emergence of central sleep apnoea in conditions such as high altitude. © 2014 The Physiological Society.

OBJECTIVE: To determine the prevalence of low health literacy and investigate the relationship between low health literacy and physical and psychological wellbeing in the Japanese general population. METHODS: A web-based cross-sectional survey was conducted in a national sample of Japanese adults. Health literacy was measured by self-report using the validated single-item screening question, 'How confident are you filling out forms by yourself?' Wellbeing was measured with the physical and psychological domains of the World Health Organization Quality of Life Assessment-BREF. Effect sizes were computed by dividing the mean difference in scores by the standard deviation of the scores of all participants. RESULTS: In 1040 adult enrollees (mean age, 57-year-old; women, 52%), there were 161 (15.5%; 95% confidence interval [CI], 13.3-17.7%) with low health literacy. Individuals with low health literacy reported lower physical wellbeing (60.6 vs. 71.7, p<0.001) and psychological wellbeing (59.7 vs. 68.3, p<0.001) compared with those with adequate health literacy. After adjusting for sociodemographic characteristics, health risk behaviors and chronic conditions, these differences were still significant (physical wellbeing, p<0.001; psychological wellbeing, p<0.001). The effect sizes of the difference of scores were moderate for physical wellbeing (-0.55) and also for psychological wellbeing (-0.44). CONCLUSION: The prevalence of self-reported low health literacy in Japanese adults is substantial and it is independently associated with poorer physical and mental wellbeing. PRACTICE IMPLICATIONS: Efforts to monitor health literacy and to evaluate causal pathways to poor wellbeing should be encouraged in the Japanese population. [ABSTRACT FROM AUTHOR]

Background: Household air pollution (HAP) is a major risk factor of non-communicable diseases, causing millions of premature deaths each year in developing nations. Populations living at high altitudes are particularly vulnerable to HAP and associated health outcomes., Objectives: This study aims to explore the relationships between activity patterns, HAP, and an HAP biomarker among 100 Himalayan nomadic households during both cooking and heating-only periods., Methods: Household CO was monitored in 100 rural homes in Qinghai, China, at 3500 m on the Himalayan Plateau among Himalayan nomads. Carboxyhemoglobin (COHb) was used as a biomarker to assess exposure among 100 male and 100 female heads of household. Linear mixed-effects models were used to explore the relationship between COHb and activity patterns., Results: Cooking periods were associated with 7 times higher household CO concentrations compared with heating periods (94 ± 56 ppm and 13 ± 11 ppm, respectively). Over the three-day biomarker-monitoring period in each house, 99% of subjects had at least one COHb measurement exceeding the WHO safety level of 2%. Cooking was associated with a 32% increase in COHb (p < 0.001)., Impact Statement: This study on household air pollution (HAP) in high-altitude regions provides important insights into the exposure patterns of nomadic households in Qinghai, China. The study found that cooking is the primary factor influencing acute carbon monoxide (CO) exposure among women, while heating alone is sufficient to elevate CO exposure above WHO guidelines. The results suggest that cooking-only interventions have the potential to reduce HAP exposure among women, but solutions for both cooking and heating may be required to reduce COHb to below WHO guidelines. This study's findings may inform future interventions for fuel and stove selection to reduce HAP and exposure among other populations., (© 2024. The Author(s).)

In some patients with acute respiratory distress syndrome (ARDS), a paradoxical improvement in respiratory system compliance (C RS ) has been observed when assuming a supine (head of bed [HOB] 0°) compared with semirecumbent (HOB 35-40°) posture. We sought to test the hypothesis that mechanically ventilated patients with ARDS would have improved C RS , due to changes in ventilation distribution, when moving from the semirecumbent to supine position. We conducted a prospective, observational ICU study including 14 mechanically ventilated patients with ARDS. For each patient, ventilation distribution (assessed by electrical impedance tomography) and pulmonary mechanics were compared in supine versus semirecumbent postures. Compared with semirecumbent, in the supine posture C RS increased (33 ± 21 vs. 26 ± 14 mL/cm H 2 O, p = 0.005), driving pressure was reduced (14 ± 6 vs. 17 ± 7 cm H 2 O, p < 0.001), and dorsal fraction of ventilation was decreased (48.5 ± 14.1% vs. 54.5 ± 12.0%, p = 0.003). Posture change from semirecumbent to supine resulted in a favorable physiologic response in terms of improved C RS and reduced driving pressure-with a corresponding increase in ventral ventilation, possibly related to reduced ventral overdistension., Competing Interests: Drs. Pearce and McGuire received funding from the National Institutes of Health- National Heart Lung and Blood Institute (NIH-NHLBI) T32. Dr. Malhotra has received funding from the National Institutes of Health (NIH). Dr. Malhotra also reports income related to medical education from Livanova, Jazz, Zoll, and Eli Lilly. ResMed gave a philanthropic donation to University of California San Diego (UCSD). Dr. Malhotra is a co-founder of Healcisio which is a startup related to predictive analytics in sepsis. The remaining authors have disclosed that they do not have any conflicts of interest related to this work., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Behavioural and psychological symptoms of dementia (BPSD) are challenging to manage, leading to caregiver burden and often to subsequent transfer of patients to a nursing home or psychiatric hospital for treatment. Eliciting favourable positive emotions should be an important goal in the treatment of negative emotions associated with BPSD. To date, no data have indicated that antipsychotic medications can improve positive emotions. BPSD are known to be associated with anxiety in patients with dementia. The traditional Chinese medicine Jia Wei Gui Pi Tang is officially indicated and approved for anxiety treatment in Japan., Methods: Here, we performed a multicentre, randomised, observer-blind control study of the effect of Jia Wei Gui Pi Tang on BPSD in Alzheimer's disease (AD) patients. Patients with AD or AD with cerebral vascular disease were randomly divided into the Jia Wei Gui Pi Tang treatment group and the control group that received no traditional Chinese medicine. BPSD were scored using the Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and by favourable positive emotions using the Delightful Emotional Index (DEI)., Results: A total of 63 participants (18 male and 45 female; mean age: 83.3 ± 6.0 years) were included in the study. Changes in NPI-NH scores differed significantly between the two groups (one-way analysis of variance, P < 0.001). Within the treatment group, there was a significant improvement in the NPI-NH score from 29.8 ± 17.3 at baseline to 13.2 ± 9.4 at the endpoint (paired t-test, P < 0.001), whereas there was no statistically significant change in the control group. Changes in DEI scores differed significantly between the two groups. Within the treatment group, there was a significant improvement in the DEI score from 24.3 ± 23.0 at baseline to 32.5 ± 21.2 at the endpoint (paired t-test, P = 0.001), whereas there was no statistically significant change in the control group., Conclusion: The traditional Chinese medicine Jia Wei Gui Pi Tang significantly improved both BPSD and positive emotions., (© 2023 The Authors. Psychogeriatrics published by John Wiley & Sons Australia, Ltd on behalf of Japanese Psychogeriatric Society.)

The purpose of this study was to explore the role of moral distress on physician burnout during COVID-19. Physicians in the US were interviewed between February and March 2021; 479 responded to our survey. The results indicated that moral distress was a key mediator in explaining the relationship between perceived organizational support, medical specialization, emotional labor, and coping with burnout. Results did not support increased burnout among female physicians, and contracting COVID-19 likewise did not play a role in burnout. Our findings suggest that physician burnout can be mitigated by increasing perceived organizational support; likewise, physicians who engaged in deep emotional labor and problem-focused coping tended to fare better when it came to feelings of moral distress and subsequent burnout.

It is well established that the early malignant tumor invades surrounding extracellular matrix (ECM) in a manner that depends upon material properties of constituent cells, surrounding ECM, and their interactions. Recent studies have established the capacity of the invading tumor spheroids to evolve into coexistent solid-like, fluid-like, and gas-like phases. Using breast cancer cell lines invading into engineered ECM, here we show that the spheroid interior develops spatial and temporal heterogeneities in material phase which, depending upon cell type and matrix density, ultimately result in a variety of phase separation patterns at the invasive front. Using a computational approach, we further show that these patterns are captured by a novel jamming phase diagram. We suggest that non-equilibrium phase separation based upon jamming and unjamming transitions may provide a unifying physical picture to describe cellular migratory dynamics within, and invasion from, a tumor., Competing Interests: The authors declare no competing interests., (© 2021 The Authors.)

We determined the efficacy of tocilizumab (TCZ) in preventing grade 2-4 acute graft-versus-host disease (aGVHD) in patients with acute leukemia or myelodysplasia undergoing matched sibling donor (MSD) or volunteer unrelated donor (VUD) allogeneic stem cell transplantation after myeloablative or reduced-intensity conditioning across 5 Australian centers. A total of 145 patients (50 MSD, 95 VUD) were randomly assigned to placebo or TCZ on day -1. All patients received T-cell-replete peripheral blood stem cell grafts and graft-versus-host disease (GVHD) prophylaxis with cyclosporin/methotrexate. A planned substudy analyzed the VUD cohort. With a median follow-up of 746 days, the incidence of grade 2-4 aGVHD at day 100 for the entire cohort was 36% for placebo vs 27% for TCZ (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.38-1.26; P = .23) and 45% vs 32% (HR, 0.61; 95% CI, 0.31-1.22; P = .16) for the VUD subgroup. The incidence of grade 2-4 aGVHD at day 180 for the entire cohort was 40% for placebo vs 29% for TCZ (HR, 0.68; 95% CI, 0.38-1.22; P = .19) and 48% vs 32% (HR, 0.59; 95% CI, 0.30-1.16; P = .13) for the VUD subgroup. Reductions in aGVHD were predominantly in grade 2 disease. For the entire cohort, transplant-related mortality occurred in 8% vs 11% of placebo-treated vs TCZ-treated patients, respectively (P = .56), and overall survival was 79% vs 71% (P = .27). Median day to neutrophil and platelet engraftment was delayed by 2 to 3 days in TCZ-treated patients, whereas liver toxicity and infectious complications were similar between groups. In this phase 3 randomized double-blind trial, TCZ showed nonsignificant trends toward reduced incidence of grade 2-4 aGVHD in recipients from HLA-matched VUDs but no improvements in long term-survival., (© 2021 by The American Society of Hematology.)

Behavioral and psychological symptoms of dementia (BPSD) challenge caregivers, leading to caregiver burden and subsequent nursing home or inpatient placement in a psychiatric hospital for dementia. Favorable positive emotions should be an important goal for the treatment of negative emotions of BPSD. Arts are one of the most profound areas to stimulate favorable emotions. We have asked a professional actor, who was not involved in the daily care and regular rehabilitations, to give a dramatic performance by reading selected stories as if the patients with BPSD felt to be in the audiences of a theater. We wondered whether a dramatic performance by the actor might be a way to respond to the complex needs of inpatients with BPSD, especially focused on favorable emotions. New inpatients (Alzheimer's disease, vascular dementia, or dementia with Lewy bodies) were randomly assigned to a control group (n = 20) and a dramatic performance group (n = 14) in Sendai Tomizawa Hospital, a psychiatric hospital for dementia, in Japan. Dramatic performances were performed for one and half hours once per week for 3 months. Neuropsychiatric Inventory for BPSD decreased in both groups and delightful emotional index (DEI) for favorable emotions increased in the intervention group but not in the control group after 3 months. At 3 months, there was an increase of DEI in intervention group compared with control group. We conclude that dramatic performance may be one of the appropriate interventions in patients with BPSD, as it appears to help in their favorable emotional state.

In development of an embryo, healing of a wound, or progression of a carcinoma, a requisite event is collective epithelial cellular migration. For example, cells at the advancing front of a wound edge tend to migrate collectively, elongate substantially, and exert tractions more forcefully compared with cells many ranks behind. With regards to energy metabolism, striking spatial gradients have recently been reported in the wounded epithelium, as well as in the tumor, but within the wounded cell layer little is known about the link between mechanical events and underlying energy metabolism. Using the advancing confluent monolayer of MDCKII cells as a model system, here we report at single cell resolution the evolving spatiotemporal fields of cell migration speeds, cell shapes, and traction forces measured simultaneously with fields of multiple indices of cellular energy metabolism. Compared with the epithelial layer that is unwounded, which is non-migratory, solid-like and jammed, the leading edge of the advancing cell layer is shown to become progressively more migratory, fluid-like, and unjammed. In doing so the cytoplasmic redox ratio becomes progressively smaller, the NADH lifetime becomes progressively shorter, and the mitochondrial membrane potential and glucose uptake become progressively larger. These observations indicate that a metabolic shift toward glycolysis accompanies collective cellular migration but show, further, that this shift occurs throughout the cell layer, even in regions where associated changes in cell shapes, traction forces, and migration velocities have yet to penetrate. In characterizing the wound healing process these morphological, mechanical, and metabolic observations, taken on a cell-by-cell basis, comprise the most comprehensive set of biophysical data yet reported. Together, these data suggest the novel hypothesis that the unjammed phase evolved to accommodate fluid-like migratory dynamics during episodes of tissue wound healing, development, and plasticity, but is more energetically expensive compared with the jammed phase, which evolved to maintain a solid-like non-migratory state that is more energetically economical.

The epithelial-to-mesenchymal transition (EMT) and the unjamming transition (UJT) each comprises a gateway to cellular migration, plasticity and remodeling, but the extent to which these core programs are distinct, overlapping, or identical has remained undefined. Here, we triggered partial EMT (pEMT) or UJT in differentiated primary human bronchial epithelial cells. After triggering UJT, cell-cell junctions, apico-basal polarity, and barrier function remain intact, cells elongate and align into cooperative migratory packs, and mesenchymal markers of EMT remain unapparent. After triggering pEMT these and other metrics of UJT versus pEMT diverge. A computational model attributes effects of pEMT mainly to diminished junctional tension but attributes those of UJT mainly to augmented cellular propulsion. Through the actions of UJT and pEMT working independently, sequentially, or interactively, those tissues that are subject to development, injury, or disease become endowed with rich mechanisms for cellular migration, plasticity, self-repair, and regeneration.

The relationship between velocities, tractions, and intercellular stresses in the migrating epithelial monolayer are currently unknown. Ten years ago, a method known as monolayer stress microscopy (MSM) was suggested from which intercellular stresses could be computed for a given traction field. The core assumption of MSM is that intercellular stresses within the monolayer obey a linear and passive constitutive law. Examples of these include a Hookean solid (an elastic sheet) or a Newtonian fluid (thin fluid film), which imply a specific relation between the displacements or velocities and the tractions. Due to the lack of independently measured intercellular stresses, a direct validation of the 2D stresses predicted by a linear passive MSM model is presently not possible. An alternative approach, which we give here and denote as the Stokes method, is based on simultaneous measurements of the monolayer velocity field and the cell-substrate tractions. Using the same assumptions as those underlying MSM, namely, a linear and passive constitutive law, the velocity field suffices to compute tractions, from which we can then compare with those measured by traction force microscopy. We find that the calculated tractions and measured tractions are uncorrelated. Since the classical MSM and the Stokes approach both depend on the linear and passive constitutive law, it follows that some serious modification of the underling rheology is needed. One possible modification is the inclusion of an active force. In the special case where this is additive to the linear passive rheology, we have a new relationship between the active force density and the measured velocity (or displacement) field and tractions, which by Newton's laws, must be obeyed.

Each cell comprising an intact, healthy, confluent epithelial layer ordinarily remains sedentary, firmly adherent to and caged by its neighbors, and thus defines an elemental constituent of a solid-like cellular collective [1,2]. After malignant transformation, however, the cellular collective can become fluid-like and migratory, as evidenced by collective motions that arise in characteristic swirls, strands, ducts, sheets, or clusters [3,4]. To transition from a solid-like to a fluid-like phase and thereafter to migrate collectively, it has been recently argued that cells comprising the disordered but confluent epithelial collective can undergo changes of cell shape so as to overcome geometric constraints attributable to the newly discovered phenomenon of cell jamming and the associated unjamming transition (UJT) [1,2,5-9]. Relevance of the jamming concept to carcinoma cells lines of graded degrees of invasive potential has never been investigated, however. Using classical in vitro cultures of six breast cancer model systems, here we investigate structural and dynamical signatures of cell jamming, and the relationship between them [1,2,10,11]. In order of roughly increasing invasive potential as previously reported, model systems examined included MCF10A, MCF10A.Vector; MCF10A.14-3-3ζ; MCF10.ErbB2, MCF10AT; and MCF10CA1a [12-15]. Migratory speed depended on the particular cell line. Unsurprisingly, for example, the MCF10CA1a cell line exhibited much faster migratory speed relative to the others. But unexpectedly, across different cell lines higher speeds were associated with enhanced size of cooperative cell packs in a manner reminiscent of a peloton [9]. Nevertheless, within each of the cell lines evaluated, cell shape and shape variability from cell-to-cell conformed with predicted structural signatures of cell layer unjamming [1]. Moreover, both structure and migratory dynamics were compatible with previous theoretical descriptions of the cell jamming mechanism [2,10,11,16,17]. As such, these findings demonstrate the richness of the cell jamming mechanism, which is now seen to apply across these cancer cell lines but remains poorly understood., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: To characterise the effects of antipsychotics on brain functions of patients with behavioural psychological symptoms of dementia (BPSD)., Methods: Studies were performed during 6 weeks of intervention with either a nonantipsychotic drug (group A, n = 38) or an antipsychotic drug (group B, n = 10)., Results: Neuropsychiatric Inventory scores were significantly decreased in both groups. Scores on the Mini-Mental State Examination did not change with intervention. By contrast, favourable natures of emotional functions, scored using the Delightful Emotional Index of 10 items, were significantly lower in the antipsychotic drug treatment group B relative to scores in the nonantipsychotic drug treatment group A., Conclusions: Antipsychotics reduce favourite emotions as well as BPSD, and this should be considered in prescribing medications for patients with dementia., (© 2019 Japanese Psychogeriatric Society.)

Patients on high inspired O 2 concentrations are at risk of atelectasis, a problem that has been quantitatively assessed using analysis of ratio of ventilation to perfusion (V̇a/Q̇) equations. This approach ignores the potential of the elastic properties of the lung to support gas exchange through "apneic" oxygenation in units with no tidal ventilation, and is based on an error in the conservation of mass equations. To fill this gap, we correct the error and compare the pressure drops associated with apneic gas exchange with the pressure differences that can be supported by lung recoil. We analyze a worst case scenario: a small test unit in the Weibel model A tree structure with zero tidal ventilation, 100% inspired O 2 , the rest of the lung being normally ventilated tidally. We first computed the gas flux to the (unventilated) test unit and estimated the associated pressure drops. We then computed the difference in local gas pressure relative to the surrounding lung that would cause the unit to collapse. We compared these two, and finally computed the degree of airway narrowing that would effect change from the stable (apneic gas exchange) regime to the unstable regime leading to collapse. We find that except under extreme conditions of loss of airway caliber exceeding roughly 90%, lung recoil is sufficient to maintain oxygenation through convective transport alone. We further argue that the fundamental V̇a/Q̇ equations are invalid in these circumstances, and that the issue of atelectasis in low V̇a/Q̇ will require modifications to account for this additional mode of gas exchange. NEW & NOTEWORTHY Breathing high concentrations of oxygen increases the likelihood of atelectasis because of oxygen absorption, which is thought to be inevitable in regions with relatively low ventilation/perfusion ratios. However, airspaces of the lung resist collapse because of the forces of interdependence, and can, with low or even zero active tidal ventilation, draw in an inspiratory flow of oxygen sufficient to replace the oxygen consumed, thus preventing collapse of airspaces served by all but the most narrowed airways.

Loss of function of the tumor suppressor p53 is known to increase the rate of migration of cells transiting the narrow pores of the traditional Boyden chamber assay. Here by contrast we investigate how p53 impacts the rate of cellular migration within a 2D confluent cell layer and a 3D collagen-embedded multicellular spheroid. We use two human carcinoma cell lines, the bladder carcinoma EJ and the colorectal carcinoma HCT116. In the confluent 2-D cell layer, for both EJ and HCT cells the migratory speeds and effective diffusion coefficients for the p53 null cells were significantly smaller than in p53-expressing cells. Compared to p53 expressers, p53-null cells exhibited more organized cortical actin rings together with reduced front-rear cell polarity. Furthermore, loss of p53 caused cells to exert smaller traction forces upon their substrates, and reduced formation of cryptic lamellipodia. In the 3D multicellular spheroid, loss of p53 consistently reduced collective cellular migration into surrounding collagen matrix. As regards the role of p53 in cellular migration, extrapolation from the Boyden chamber assay to other cellular microenvironments is seen to be fraught even in terms of the sign of the effect. Together, these paradoxical results show that the effects of p53 on cellular migration are context-dependent., Competing Interests: The authors have declared that no competing interests exist.

Background: Hospital linens and patient gowns are frequently touched and contaminated, and may contribute to endogenous, indirect-contact, and aerosol transmission of nosocomial-related pathogens. Recently Sentara Healthcare adopted biocidal copper oxide-impregnated linens across its hospitals., Aim: To assess whether the replacement of the linens resulted in the reduction of healthcare-associated infection (HCAI)., Methods: Rates of HCAI caused by Clostridium difficile and multidrug-resistant organisms (MDROs) were compared in six Sentara Healthcare hospitals with similar patient demo-graphics (total of 1019 beds) in three parallel periods (90, 180 and 240 days) before and after (periods A1, A2 and A3, and periods B1, B2, and B3, respectively), replacing all the regular non-biocidal linens with the copper oxide-impregnated biocidal linens., Findings: During periods B1, B2, and B3, compared with periods A1, A2 and A3, there were 61.2% (P < 0.05), 41.1% (P < 0.05) and 42.9% (P < 0.01) reductions in HCAI per 10,000 patient-days in hospital caused by C. difficile, respectively; 48.3% (P > 0.05), 36.4% (P > 0.05), and 19.2% (P > 0.05) reductions in HCAI per 1000 patient-days caused by MDROs; and 59.8% (P < 0.01), 39.9% (P < 0.05), and 37.2% (P < 0.05) in the reduction of HCAI per 1000 patient-days caused by C. difficile and MDROs combined., Conclusion: The use of biocidal copper oxide-impregnated linens in the six analysed Sentara Healthcare hospitals resulted in significant reduction in both HCAI caused by C. difficile, and the combined metric of C. difficile or MDRO infection. Similar reductions in HCAI caused by MDROs were observed, although these reductions did not reach statistical significance, probably due to very low HCAI rates caused by these pathogens in the study facilities., (Copyright © 2018. Published by Elsevier Ltd.)

During acute bronchoconstriction, the airway epithelium becomes mechanically compressed, as airway smooth muscle contracts and the airway narrows. This mechanical compression activates airway epithelium to promote asthmatic airway remodeling. However, whether compressed airway epithelium can feed back on the cause of bronchoconstriction has remained an open question. Here we examine the potential for epithelial compression to augment proliferation and contraction of airway smooth muscle, and thus potentiate further bronchoconstriction and epithelial compression. Well-differentiated primary human bronchial epithelial (HBE) cells maintained in air-liquid interface culture were mechanically compressed to mimic the effect of bronchoconstriction. Primary human airway smooth muscle (HASM) cells were incubated with conditioned media collected from mechanically compressed HBE cells to examine the effect of epithelial-derived mediators on HASM cell proliferation using an EdU assay and HASM cell contraction using traction microscopy. An endothelin receptor antagonist, PD-145065, was employed to probe the role of HBE cell-derived endothelin-1 on the proliferation and contraction of HASM cells. Conditioned media from compressed HBE cells increased HASM cell proliferation, independent of the endothelin-1 signaling pathway. However, conditioned media from compressed HBE cells significantly increased HASM cell basal contraction and histamine-induced contraction, both of which depended on the endothelin-1 signaling pathway. Our data demonstrate that mechanical compression of bronchial epithelial cells contributes to proliferation and basal contraction of airway smooth muscle cells and that augmented contraction depends on epithelial cell-derived endothelin-1. By means of both airway smooth muscle remodeling and contractility, our findings suggest a causal role of epithelial compression on asthma pathogenesis.

A possible precision-medicine approach to treating obstructive sleep apnoea (OSA) involves targeting ventilatory instability (elevated loop gain) using supplemental inspired oxygen in selected patients. Here we test whether elevated loop gain and three key endophenotypic traits (collapsibility, compensation and arousability), quantified using clinical polysomnography, can predict the effect of supplemental oxygen on OSA severity.36 patients (apnoea-hypopnoea index (AHI) >20 events·h -1 ) completed two overnight polysomnographic studies (single-blinded randomised-controlled crossover) on supplemental oxygen (40% inspired) versus sham (air). OSA traits were quantified from the air-night polysomnography. Responders were defined by a ≥50% reduction in AHI (supine non-rapid eye movement). Secondary outcomes included blood pressure and self-reported sleep quality.Nine of 36 patients (25%) responded to supplemental oxygen (ΔAHI=72±5%). Elevated loop gain was not a significant univariate predictor of responder/non-responder status (primary analysis). In post hoc analysis, a logistic regression model based on elevated loop gain and other traits (better collapsibility and compensation; cross-validated) had 83% accuracy (89% before cross-validation); predicted responders exhibited an improvement in OSA severity (ΔAHI 59±6% versus 12±7% in predicted non-responders, p=0.0001) plus lowered morning blood pressure and "better" self-reported sleep.Patients whose OSA responds to supplemental oxygen can be identified by measuring their endophenotypic traits using diagnostic polysomnography., Competing Interests: Conflict of interest: S.A. Sands reports grants from NIH and AHA, during the conduct of the study; and personal fees from Cambridge Sound Management, Nox Medical and Merck, outside the submitted work. Conflict of interest: B.A. Edwards received a salary from Heart Foundation of Australia, during the conduct of the study. Conflict of interest: P.I. Terrill reports grants from Australian National Health and Medical Research Council (1064163), during the conduct of the study; and grants from Hull Family Donation, 2014, outside the submitted work. Conflict of interest: J.P. Butler has nothing to disclose. Conflict of interest: R.L. Owens reports personal fees for consultancy from Novartis, and honoraria and travel reimbursement from ResMed and Itamar Medical, outside the submitted work. Conflict of interest: L. Taranto-Montemurro reports grants from American Heart Association, personal fees from Novion Pharmaceuticals and Cambridge Sound management, and other from Apnimed, outside the submitted work. Conflict of interest: A. Azarbarzin has nothing to disclose. Conflict of interest: M. Marques has nothing to disclose. Conflict of interest: L.B. Hess has nothing to disclose. Conflict of interest: E.T. Smales has nothing to disclose. Conflict of interest: C.M. de Melo has nothing to disclose. Conflict of interest: D.P. White reports personal fees from Philips Respironics (Chief Scientific Officer), personal fees for consultancy from Night Balance, and personal fees from Apnicure (previously Chief Medical Officer), outside the submitted work. Conflict of interest: A. Malhotra relinquished all outside personal income in 2012 as an Officer of the American Thoracic Society. ResMed provided a philanthropic donation to University College San Diego in support of a sleep centre. Conflict of interest: A. Wellman reports grants from National Institutes of Health and Philips Respironics, during the conduct of the study; grants from Varnum Sleep and Breathing Solutions and Cambridge Sound Management, and personal fees from Bayer and Nox Medical, outside the submitted work; in addition, A. Wellman has a patent Airway and Airflow Factors issued., (Copyright ©ERS 2018.)

At the edge of a confluent cell layer, cell-free empty space is a cue that can drive directed collective cellular migration. Similarly, contact guidance is also a robust mechanical cue that can drive cell migration. However, it is unclear which of the two effects is stronger, and how each mechanism affects collective migration. To address this question, here we explore the trajectories of cells migrating collectively on a substrate containing micropatterned grooves (10-20 μm in periodicity, 2 μm in height) compared with unpatterned control substrates. Compared with unpatterned controls, the micropatterned substrates attenuated path variance by close to 70% and augmented migration coordination by more than 30%. Together, these results show that contact guidance can play an appreciable role in collective cellular migration. Also, our result can provide insights into tissue repair and regeneration with the remodeling of the connective tissue matrix.

As an injury heals, an embryo develops, or a carcinoma spreads, epithelial cells systematically change their shape. In each of these processes cell shape is studied extensively whereas variability of shape from cell-to-cell is regarded most often as biological noise. But where do cell shape and its variability come from? Here we report that cell shape and shape variability are mutually constrained through a relationship that is purely geometrical. That relationship is shown to govern processes as diverse as maturation of the pseudostratified bronchial epithelial layer cultured from non-asthmatic or asthmatic donors, and formation of the ventral furrow in the Drosophila embryo. Across these and other epithelial systems, shape variability collapses to a family of distributions that is common to all. That distribution, in turn, is accounted for by a mechanistic theory of cell-cell interaction showing that cell shape becomes progressively less elongated and less variable as the layer becomes progressively more jammed. These findings suggest a connection between jamming and geometry that spans living organisms and inert jammed systems, and thus transcends system details. Although molecular events are needed for any complete theory of cell shape and cell packing, observations point to the hypothesis that jamming behavior at larger scales of organization sets overriding geometrical constraints.

With every deep inspiration (DI) or sigh, the airway wall stretches, as do the airway smooth muscle cells in the airway wall. In response, the airway smooth muscle cell undergoes rapid stretch-induced cytoskeletal fluidization. As a molecular mechanism underlying the cytoskeletal fluidization response, we demonstrate a key role for the actin-severing protein cofilin. Using primary human airway smooth muscle cells, we simulated a DI by imposing a transient stretch of physiological magnitude and duration. We used traction microscopy to measure the resulting changes in contractile forces. After a transient stretch, cofilin-knockdown cells exhibited a 29 ± 5% decrease in contractile force compared with prestretch conditions. By contrast, control cells exhibited a 67 ± 6% decrease ( P < 0.05, knockdown vs. control). Consistent with these contractile force changes with transient stretch, actin filaments in cofilin-knockdown cells remained largely intact, whereas actin filaments in control cells were rapidly disrupted. Furthermore, in cofilin-knockdown cells, contractile force at baseline was higher and rate of remodeling poststretch was slower than in control cells. Additionally, the severing action of cofilin was restricted to the release phase of the transient stretch. We conclude that the actin-severing activity of cofilin is an important factor in stretch-induced cytoskeletal fluidization and may account for an appreciable part of the bronchodilatory effects of a DI.

In endothelial gap formation, local tractions exerted by the cell upon its basal adhesions are thought to exceed balancing tensile stresses exerted across the cell-cell junction, thus causing the junction to rupture. To test this idea, we mapped evolving tractions, intercellular stresses, and corresponding growth of paracellular gaps in response to agonist challenge. Contrary to expectation, we found little to no relationship between local tensile stresses and gap formation. Instead, we discovered that intercellular stresses were aligned into striking multi-cellular domains punctuated by defects in stress alignment. Surprisingly, gaps emerged preferentially not at stress hotspots, as predicted, but rather at stress defects. This unexpected behavior is captured by a minimal model of the cell layer as a jammed assembly of cohesive particles undergoing plastic rearrangements under tension. Together, experiments and model suggest a new physical picture in which gap formation, and its consequent effect on endothelial permeability, is determined not by a local stress imbalance at a cell-cell junction but rather by emergence of non-local, cooperative stress reorganization across the cellular collective., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Objectives: Precision medicine for obstructive sleep apnea (OSA) requires noninvasive estimates of each patient's pathophysiological "traits." Here, we provide the first automated technique to quantify the respiratory arousal threshold-defined as the level of ventilatory drive triggering arousal from sleep-using diagnostic polysomnographic signals in patients with OSA., Methods: Ventilatory drive preceding clinically scored arousals was estimated from polysomnographic studies by fitting a respiratory control model (Terrill et al.) to the pattern of ventilation during spontaneous respiratory events. Conceptually, the magnitude of the airflow signal immediately after arousal onset reveals information on the underlying ventilatory drive that triggered the arousal. Polysomnographic arousal threshold measures were compared with gold standard values taken from esophageal pressure and intraoesophageal diaphragm electromyography recorded simultaneously (N = 29). Comparisons were also made to arousal threshold measures using continuous positive airway pressure (CPAP) dial-downs (N = 28). The validity of using (linearized) nasal pressure rather than pneumotachograph ventilation was also assessed (N = 11)., Results: Polysomnographic arousal threshold values were correlated with those measured using esophageal pressure and diaphragm EMG (R = 0.79, p < .0001; R = 0.73, p = .0001), as well as CPAP manipulation (R = 0.73, p < .0001). Arousal threshold estimates were similar using nasal pressure and pneumotachograph ventilation (R = 0.96, p < .0001)., Conclusions: The arousal threshold in patients with OSA can be estimated using polysomnographic signals and may enable more personalized therapeutic interventions for patients with a low arousal threshold., (© Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Sleep loss causes profound cognitive impairments and increases the concentrations of adenosine and adenosine A1 receptors in specific regions of the brain. Time courses for performance impairment and recovery differ between acute and chronic sleep loss, but the physiological basis for these time courses is unknown. Adenosine has been implicated in pathways that generate sleepiness and cognitive impairments, but existing mathematical models of sleep and cognitive performance do not explicitly include adenosine. Here, we developed a novel receptor-ligand model of the adenosine system to test the hypothesis that changes in both adenosine and A1 receptor concentrations can capture changes in cognitive performance during acute sleep deprivation (one prolonged wake episode), chronic sleep restriction (multiple nights with insufficient sleep), and subsequent recovery. Parameter values were estimated using biochemical data and reaction time performance on the psychomotor vigilance test (PVT). The model closely fit group-average PVT data during acute sleep deprivation, chronic sleep restriction, and recovery. We tested the model's ability to reproduce timing and duration of sleep in a separate experiment where individuals were permitted to sleep for up to 14 hours per day for 28 days. The model accurately reproduced these data, and also correctly predicted the possible emergence of a split sleep pattern (two distinct sleep episodes) under these experimental conditions. Our findings provide a physiologically plausible explanation for observed changes in cognitive performance and sleep during sleep loss and recovery, as well as a new approach for predicting sleep and cognitive performance under planned schedules.

Study Objectives: In principle, if metabolic rate were to fall during sleep in a patient with obstructive sleep apnea (OSA), ventilatory requirements could be met without increased respiratory effort thereby favoring stable breathing. Indeed, most patients achieve periods of stable flow-limited breathing without respiratory events for periods during the night for reasons that are unclear. Thus, we tested the hypothesis that in patients with OSA, periods of stable breathing occur when metabolic rate (VO2) declines., Methods: Twelve OSA patients (apnea-hypopnea index >15 events/h) completed overnight polysomnography including measurements of VO2 (using ventilation and intranasal PO2) and respiratory effort (esophageal pressure)., Results: Contrary to our hypothesis, VO2 did not differ between stable and unstable breathing periods in non-REM stage 2 (208 ± 20 vs. 213 ± 18 mL/min), despite elevated respiratory effort during stable breathing (26 ± 2 versus 23 ± 2 cmH2O, p = .03). However, VO2 was lowered during deeper sleep (244 to 179 mL/min from non-REM stages 1 to 3, p = .04) in conjunction with more stable breathing. Further analysis revealed that airflow obstruction curtailed metabolism in both stable and unstable periods, since CPAP increased VO2 by 14% in both cases (p = .02, .03, respectively). Patients whose VO2 fell most during sleep avoided an increase in PCO2 and respiratory effort., Conclusions: OSA patients typically convert from unstable to stable breathing without lowering metabolic rate. During sleep, OSA patients labor with increased respiratory effort but fail to satisfy metabolic demand even in the absence of overt respiratory events., (© Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Background: OSA results from the collapse of different pharyngeal structures (soft palate, tongue, lateral walls, and epiglottis). The structure involved in collapse has been shown to impact non-CPAP OSA treatment. Different inspiratory airflow shapes are also observed among patients with OSA. We hypothesized that inspiratory flow shape reflects the underlying pharyngeal structure involved in airway collapse., Methods: Subjects with OSA were studied with a pediatric endoscope and simultaneous nasal flow and pharyngeal pressure recordings during natural sleep. The mechanism causing collapse was classified as tongue-related, isolated palatal, lateral walls, or epiglottis. Flow shape was classified according to the degree of negative effort dependence (NED), defined as the percent reduction in inspiratory flow from peak to plateau., Results: Thirty-one subjects with OSA (mean apnea-hypopnea index score ± SD, 54 ± 27 events/h) who were 50 ± 9 years of age were studied. NED was associated with the structure causing collapse (P < .001). Tongue-related obstruction (n = 13) was associated with a small amount of NED (median, 19; interquartile range [IQR], 14%-25%). Moderate NED was found among subjects with isolated palatal collapse (median, 45; IQR, 39%-52%; n = 8) and lateral wall collapse (median, 50; IQR, 44%-64%; n = 8). The epiglottis was associated with severe NED (median, 89; IQR, 78%-91%) and abrupt discontinuities in inspiratory flow (n = 9)., Conclusions: Inspiratory flow shape is influenced by the pharyngeal structure causing collapse. Flow shape analysis may be used as a noninvasive tool to help determine the pharyngeal structure causing collapse., (Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose: The primary aim of this study was to compare the effectiveness of olanzapine, palonosetron and ondansetron infusion (standard of care) for the treatment of breakthrough chemotherapy-induced nausea and vomiting (CINV) in patients undergoing hematopoietic stem cell transplantation (HSCT)., Method: It was a randomized open-label prospective study. Sixty-two patients were randomized to receive either ondansetron 32-mg infusion over 24 h, or olanzapine wafer 10 mg once daily in addition to ondansetron 8 mg IV three times a day or a single dose of palonosetron 0.25 mg IV instead of ondansetron. All groups were allowed rescue antiemetics. The primary endpoint was a composite outcome of no emesis, no use of rescue medication, and nausea score reduction of ≥50 %. The secondary endpoint was nausea score reduction of ≥50 %. Both endpoints were measured at 24 and 48 h after initiation of the study treatment. Statistical analysis was conducted using a double-sided Fisher's exact test., Result: The primary endpoint was achieved in 6, 45, and 18 %, and 6, 64, and 18 % of ondansetron versus olanzapine versus palonosetron patient groups at 24 and 48 h, respectively. The secondary outcome was observed in 17, 60, and 62 %, and 35, 71, and 43 % of ondansetron versus olanzapine versus palonosetron patient groups at 24 and 48 h, respectively. Serious adverse drug reactions were not reported in any arms. Time to engraftment was not significantly different between the arms., Conclusions: Olanzapine was an effective treatment of breakthrough CINV. A single dose of palonosetron significantly reduced nausea up to 24 h.

Rationale: In patients with chronic heart failure, daytime oscillatory breathing at rest is associated with a high risk of mortality. Experimental evidence, including exaggerated ventilatory responses to CO 2 and prolonged circulation time, implicates the ventilatory control system and suggests feedback instability (loop gain > 1) is responsible. However, daytime oscillatory patterns often appear remarkably irregular versus classic instability (Cheyne-Stokes respiration), suggesting our mechanistic understanding is limited., Objectives: We propose that daytime ventilatory oscillations generally result from a chemoreflex resonance, in which spontaneous biological variations in ventilatory drive repeatedly induce temporary and irregular ringing effects. Importantly, the ease with which spontaneous biological variations induce irregular oscillations (resonance "strength") rises profoundly as loop gain rises toward 1. We tested this hypothesis through a comparison of mathematical predictions against actual measurements in patients with heart failure and healthy control subjects., Methods: In 25 patients with chronic heart failure and 25 control subjects, we examined spontaneous oscillations in ventilation and separately quantified loop gain using dynamic inspired CO 2 stimulation., Measurements and Main Results: Resonance was detected in 24 of 25 patients with heart failure and 18 of 25 control subjects. With increased loop gain-consequent to increased chemosensitivity and delay-the strength of spontaneous oscillations increased precipitously as predicted (r = 0.88), yielding larger (r = 0.78) and more regular (interpeak interval SD, r = -0.68) oscillations (P < 0.001 for all, both groups combined)., Conclusions: Our study elucidates the mechanism underlying daytime ventilatory oscillations in heart failure and provides a means to measure and interpret these oscillations to reveal the underlying chemoreflex hypersensitivity and reduced stability that foretells mortality in this population.

We examined the effects of provider characteristics on home health agency performance on patient experience of care (Home Health CAHPS) and process (OASIS) measures. Descriptive, multivariate, and factor analyses were used. While agencies score high on both domains, factor analyses showed that the underlying items represent separate constructs. Freestanding and Visiting Nurse Association agencies, higher number of home health aides per 100 episodes, and urban location were statistically significant predictors of lower performance. Lack of variation in composite measures potentially led to counterintuitive results for effects of organizational characteristics. This exploratory study showed the value of having separate quality domains.

The cytoskeleton (CSK) is a tensed fiber framework that supports, shapes and stabilizes the cell. The CSK is in a constant state of remodeling, moreover, which is an active non-equilibrium thermodynamic process. We report here that cytoskeletal remodeling involves reconfigurations that are not only sudden but also are transmitted to great distances within the cell in a fashion reminiscent of quakes in the Earth's crust. Remarkably, these events in the cell conform both qualitatively and quantitatively to empirical laws typical of earthquakes, including hierarchical fault structures, cumulative energy distributions following the Gutenberg-Richter law, and rate of after-shocks following Omori's law. While it is well-established that remodeling and stabilization of the cytoskeleton are non-equilibrium process, these new unanticipated observations establish that these processes are also remarkably non-local and strongly cooperative.

Collective cellular migration within the epithelial layer impacts upon development, wound healing and cancer invasion, but remains poorly understood. Prevailing conceptual frameworks tend to focus on the isolated role of each particular underlying factor - taken one at a time or at most a few at a time - and thus might not be tailored to describe a cellular collective that embodies a wide palette of physical and molecular interactions that are both strong and complex. To bridge this gap, we shift the spotlight to the emerging concept of cell jamming, which points to only a small set of parameters that govern when a cellular collective might jam and rigidify like a solid, or instead unjam and flow like a fluid. As gateways to cellular migration, the unjamming transition (UJT) and the epithelial-to-mesenchymal transition (EMT) share certain superficial similarities, but their congruence - or lack thereof - remains unclear. In this Commentary, we discuss aspects of cell jamming, its established role in human epithelial cell layers derived from the airways of non-asthmatic and asthmatic donors, and its speculative but emerging roles in development and cancer cell invasion., Competing Interests: The authors declare no competing or financial interests., (© 2016. Published by The Company of Biologists Ltd.)