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Objective: Flow and laser scanning cytometry are used extensively in research and clinical settings. These techniques provide clinicians and scientists information about cell functioning in a variety of health and disease states. An in-depth knowledge and understanding of cytometry techniques can enhance interpretation of current research findings. Our goal with this review is to reacquaint clinicians and scientists with information concerning differences between flow and laser scanning cytometry by comparing their capabilities and applications.Methods: A Pubmed abstract search was conducted for articles on research, reviews and current texts relating to origins and use of flow and laser scanning cytometry. Attention was given to studies describing application of these techniques in the clinical setting.Results: Both techniques exploit interactions between the physical properties of light. Data are immediately and automatically acquired; they are distinctly different. Flow cytometry provides valuable rapid information about a wide variety of cellular or particle characteristics. This technique does not provide the scanned high resolution image analysis needed for investigators to localize areas of interest within the cell for quantification. Flow cytometry requires that the sample contain a large amount disaggregated, single, suspended cells. Laser scanning cytometry is slide-based and does not require as large of a sample. The tissue sample is affixed to a slide allowing repeated sample analyses. These cytometry techniques are used in the clinical setting to understand pathophysiological derangements associated with many diseases; cardiovascular disease, diabetes, acute lung injury, hemorrhagic shock, surgery, cancer and Alzheimer's disease.Conclusions: Understanding the differences between FCM and LSCM can assist investigators in planning and design of their research or clinical testing. Researchers and clinicians optimize these technique capabilities with the cellular characteristics they wish to measure delineating molecular and cellular events occurring in health and disease. Discovery of mechanisms in cells using FCM and LSCM provide evidence needed to guide future treatment and interventions. [ABSTRACT FROM AUTHOR]

Background: Vasoactive drug infusion rates are titrated to achieve a desired effect, e.g., mean arterial blood pressure (MAP), rather than using infusion rates based on body weight. The purpose of this study is to evaluate a method to automatically identify a patient's sensitivity to sodium-nitroprusside, dobutamine or dopamine and to evaluate, whether an advisory system that predicts MAP 5 min in the future enhances a clinician's ability to titrate sodium-nitroprusside infusions.Methods: We used published models implemented in MATLAB to simulate the response of 100 individual patients to infusions of sodium-nitroprusside, dopamine and dobutamine. The simulated patient's sensitivity to the three drugs was identified using an adaptive filter approach, where MAP was altered in a binary stepwise fashion. Next, 9 nurses were asked to control the MAP of 6 of the simulated patients. For half of the patients, we used the identified sensitivity to predict and display MAP 5 min into the future.Results: Identifying each individual patient's sensitivity improved the accuracy of the MAP prediction by 75% for sodium-nitroprusside, 82% for dopamine and 52% for dobutamine over the MAP prediction based on an "average" patient's sensitivity. The advisory system shortened the median time to reach the desired MAP from 10.2 to 4.1 min, decreased the median number of infusion rate changes from 6 to 4, and resulted in a significant reduction of mental workload and effort.Discussion: Patient-specific drug sensitivity identifi- cation significantly improved the prediction of future MAP. By predicting and displaying the expected MAP 5 min in the future, the advisory system helped nurses titrate faster, reduced their perceived workload and might improve patient safety. [ABSTRACT FROM AUTHOR]

BACKGROUND: Anatomic dead space (also called airway or tracheal dead space) is the part of the tidal volume that does not participate in gas exchange. Some contemporary ventilation protocols, such as the Acute Respiratory Distress Syndrome Network protocol, call for smaller tidal volumes than were traditionally delivered. With smaller tidal volumes, the percentage of each delivered breath that is wasted in the anatomic dead space is greater than it is with larger tidal volumes. Many respiratory and medical textbooks state that anatomic dead space can be estimated from the patient's weight by assuming there is approximately 1 mL of dead space for every pound of body weight. With a volumetric capnography monitor that measures on-airway flow and CO(2), the anatomic dead space can be automatically and directly measured with the Fowler method, in which dead space equals the exhaled volume up to the point when CO(2) rises above a threshold. METHODS: We analyzed data from 58 patients (43 male, 15 female) to assess the accuracy of 5 anatomic dead space estimation methods. Anatomic dead space was measured during the first 10 min of monitoring and compared to the estimates. RESULTS: The coefficient of determination (r(2)) between the anatomic dead space estimate based on body weight and the measured anatomic dead space was r(2) = 0.0002. The mean +/- SD error between the body weight estimate and the measured dead space was 60 +/- 54 mL. CONCLUSIONS: It appears that the anatomic dead space estimate methods were sufficient when used (as originally intended) together with other assumptions to identify a starting point in a ventilation algorithm, but the poor agreement between an individual patient's measured and estimated anatomic dead space contradicts the assumption that dead space can be predicted from actual or ideal weight alone. [ABSTRACT FROM AUTHOR]

Nurse education has to confront the problem of developing in students an understanding of the different perspectives put forward in nursing. However, all the perspectives adhere to the scientific method and it is therefore necessary to examine the process of scientific inquiry. As nursing occupies a position at the interface between physical and social sciences, it is also necessary to offer students an examination of the different paradigms which exist within the social sciences. [ABSTRACT FROM AUTHOR]

Presents a brief review of papers published in the 'Journal of Advanced Nursing,' 1983–1992. Classification of paper; Topics covered in the papers; Number of publications and papers featured.

Abstract Background The teleost order Lophiiformes, commonly known as the anglerfishes, contains a diverse array of marine fishes, ranging from benthic shallow-water dwellers to highly modified deep-sea midwater species. They comprise 321 living species placed in 68 genera, 18 families and 5 suborders, but approximately half of the species diversity is occupied by deep-sea ceratioids distributed among 11 families. The evolutionary origins of such remarkable habitat and species diversity, however, remain elusive because of the lack of fresh material for a majority of the deep-sea ceratioids and incompleteness of the fossil record across all of the Lophiiformes. To obtain a comprehensive picture of the phylogeny and evolutionary history of the anglerfishes, we assembled whole mitochondrial genome (mitogenome) sequences from 39 lophiiforms (33 newly determined during this study) representing all five suborders and 17 of the 18 families. Sequences of 77 higher teleosts including the 39 lophiiform sequences were unambiguously aligned and subjected to phylogenetic analysis and divergence time estimation. Results Partitioned maximum likelihood analysis confidently recovered monophyly for all of the higher taxa (including the order itself) with the exception of the Thaumatichthyidae (Lasiognathus was deeply nested within the Oneirodidae). The mitogenomic trees strongly support the most basal and an apical position of the Lophioidei and a clade comprising Chaunacoidei + Ceratioidei, respectively, although alternative phylogenetic positions of the remaining two suborders (Antennarioidei and Ogcocephaloidei) with respect to the above two lineages are statistically indistinguishable. While morphology-based intra-subordinal relationships for relatively shallow, benthic dwellers (Lophioidei, Antennarioidei, Ogcocephaloidei, Chaunacoidei) are either congruent with or statistically indistinguishable from the present mitogenomic tree, those of the principally deep-sea midwater dwellers (Ceratioidei) cannot be reconciled with the molecular phylogeny. A relaxed molecular-clock Bayesian analysis of the divergence times suggests that all of the subordinal diversifications have occurred during a relatively short time period between 100 and 130 Myr ago (early to mid Cretaceous). Conclusions The mitogenomic analyses revealed previously unappreciated phylogenetic relationships among the lophiiform suborders and ceratioid familes. Although the latter relationships cannot be reconciled with the earlier hypotheses based on morphology, we found that simple exclusion of the reductive or simplified characters can alleviate some of the conflict. The acquisition of novel features, such as male dwarfism, bioluminescent lures, and unique reproductive modes allowed the deep-sea ceratioids to diversify rapidly in a largely unexploited, food-poor bathypelagic zone (200-2000 m depth) relative to the other lophiiforms occurring in shallow coastal areas.

Abstract Background Free-ranging narwhals (Monodon monoceros) were instrumented in Admiralty Inlet, Canada with both satellite tags to study migration and stock separation and short-term, high-resolution digital archival tags to explore diving and feeding behaviour. Three narwhals were equipped with an underwater camera pod (Crittercam), another individual was equipped with a digital archival tag (DTAG), and a fifth with both units during August 2003 and 2004. Results Crittercam footage indicated that of the combined 286 minutes of recordings, 12% of the time was spent along the bottom. When the bottom was visible in the camera footage, the narwhals were oriented upside-down 80% of the time (range: 61100%). The DTAG data (14.6 hours of recordings) revealed that during time spent below the surface, the two tagged narwhals were supine an average of 13% (range: 9–18%) of the time. Roughly 70% of this time spent in a supine posture occurred during the descent. Conclusion Possible reasons for this upside-down swimming behaviour are discussed. No preference for a clockwise or counter-clockwise direction of roll was observed, discounting the possibility that rolling movements contribute to the asymmetric left-handed helical turns of the tusk.

Background: Survivors of breast and prostate cancer, especially those that are Black and/or Hispanic, are at high risk for cardiovascular events. Physical activity can reduce the risk of cardiovascular events in cancer survivors, but Black and Hispanic people are less likely to engage in routine physical activity. Concepts from behavioral economics have been used to design scalable, low-touch, gamification interventions that increase physical activity in individuals at high risk for cardiovascular events, but the effectiveness of these strategies in Black and Hispanic survivors of breast and prostate cancer is uncertain., Study Design and Objectives: ALLSTAR (NCT05176756) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of a gamification intervention informed by behavioral economic concepts to increase daily physical activity in Black and Hispanic breast and prostate cancer survivors who received cardiotoxic therapies and have additional risk factors for cardiovascular disease. Patients were either referred by their cancer care team or identified by electronic health record searches; contacted by letter, email, text message and/or phone; and complete enrollment and informed consent on the Penn Way to Health online platform. Patients are then provided with a wearable fitness tracker, establish a baseline daily step count, set a goal to increase daily step count by 1500-3000 steps from baseline, and are randomized 1:1 to control or gamification. Interventions continue for 6 months, with follow-up for an additional 3 months to evaluate the durability of behavior change. The trial has met its enrollment goal of 150 participants, with a primary endpoint of change from baseline in daily steps over the 6-month intervention period. Key secondary endpoints include change from baseline in daily steps over the 3-month post-intervention follow-up period, change in moderate to vigorous physical activity over the intervention and follow-up periods, and change in patient-reported measures of physical function, fatigue, and overall quality of life., Conclusions: ALLSTAR is a virtual, pragmatic randomized clinical trial powered to demonstrate whether gamification is superior to control in increasing physical activity in Black and Hispanic breast and prostate cancer survivors. Its results will have important implications for strategies to promote physical activity in survivors of breast and prostate cancer, specifically among minority populations., Clinical Trial Registration: clinicaltrials.gov; https://clinicaltrials.gov/study/NCT05176756., Competing Interests: Declaration of competing interest Dr. Volpp is a co-owner of a behavioral economics consulting firm, VAL Health, and a member of the Scientific Advisory Board of THRIVE Global. Neither organization has any involvement in this study. All other authors report no relevant conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: Ataxic breathing (AB) is a well-known manifestation of opioid effects in animals and humans, but is not routinely included in monitoring for opioid-induced respiratory depression (OIRD). We quantified AB in normal volunteers receiving increasing doses of remifentanil. We used a support vector machine (SVM) learning approach with features derived from a modified Poincaré plot. We tested the hypothesis that AB may be found when bradypnea and reduced mental status are not present., Methods: Twenty-six healthy volunteers (13 female) received escalating target effect-site concentrations of remifentanil with a low baseline dose of propofol to simulate typical breathing patterns in drowsy patients who had received parenteral opioids. We derived respiratory rate (RR) from respiratory inductance plethysmography, mental alertness from the Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S), and AB severity on a 0 to 4 scale (categories ranging from none to severe) from the SVM. The primary outcome measure was sensitivity and specificity for AB to detect OIRD., Results: All respiratory measurements were obtained from unperturbed subjects during steady state in 121 assessments with complete data. The sensitivity of AB for detecting OIRD by the conventional method was 92% and specificity was 28%. As expected, 69 (72%) of the instances not diagnosed as OIRD using conventional measures were observed to have at least moderate AB., Conclusions: AB was frequently present in the absence of traditionally detected OIRD as defined by reduced mental alertness (MOAA/S score of <4) and bradypnea (RR <8 breaths/min). These results justify the need for future trials to explore replicability with other opioids and clinical utility of AB as an add-on measure in recognizing OIRD., Competing Interests: Conflicts of interest, Funding: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Climate change and human land use are considered key threats to freshwater invertebrates. Heatwaves can impact the phenology of insects and population dynamics, yet have been largely ignored in experiments compared to mean temperature changes. Another major anthropogenic stressor driving invertebrate community changes is deposited fine sediment; therefore, effects of key climate-change drivers on invertebrate drift and insect emergence rates may differ between sediment-impacted and non-impacted streams. However, this has never been tested in a realistic outdoor experiment. We investigated the individual and combined effects of two 7-day heatwaves, CO 2 enrichment, flow velocity variability (periods of fast and slow) and fine sediment on stream drift and emergence responses, sampled four times during a 7-week experiment in 128 flow-through stream mesocosms. We examined invertebrate drift and insect emergence responses to the four stressors, and used these responses to help explain the benthic invertebrate community responses already assessed (sampled at the end of the experiment). Heatwave 1 strongly increased emergence (dominated by Chironomidae), causing an earlier emergence peak, an effect not repeated during heatwave 2, seven days later. During heatwave 1, emerged chironomids were larger in heated channels, but smaller in heated channels afterwards, suggesting a different effect on body size of short-term heatwaves to previous constant warming experiments. CO 2 enrichment reduced drifting EPT and total and Chironomidae emergence on three sampling occasions each. After heatwave 1, total drift and total emergence were strongly reduced by heating in ambient-CO 2 channels, whereas no reduction occurred in CO 2 -enriched channels. During heatwave 2, total drift increased in channels without sediment but not in channels with added sediment. Overall, our findings suggest heatwaves can shift the timing of stream insect emergence, regardless of longer-term mean temperatures. They also show that heatwaves, raised CO 2 , and fine sediment can modulate each others' effects on drift and emergence dynamics., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Understanding the interactions among anthropogenic stressors is critical for effective conservation and management of ecosystems. Freshwater scientists have invested considerable resources in conducting factorial experiments to disentangle stressor interactions by testing their individual and combined effects. However, the diversity of stressors and systems studied has hindered previous syntheses of this body of research. To overcome this challenge, we used a novel machine learning framework to identify relevant studies from over 235,000 publications. Our synthesis resulted in a new dataset of 2396 multiple-stressor experiments in freshwater systems. By summarizing the methods used in these studies, quantifying trends in the popularity of the investigated stressors, and performing co-occurrence analysis, we produce the most comprehensive overview of this diverse field of research to date. We provide both a taxonomy grouping the 909 investigated stressors into 31 classes and an open-source and interactive version of the dataset (https://jamesaorr.shinyapps.io/freshwater-multiple-stressors/). Inspired by our results, we provide a framework to help clarify whether statistical interactions detected by factorial experiments align with stressor interactions of interest, and we outline general guidelines for the design of multiple-stressor experiments relevant to any system. We conclude by highlighting the research directions required to better understand freshwater ecosystems facing multiple stressors., (© 2024 The Author(s). Ecology Letters published by John Wiley & Sons Ltd.)

Climate change and land-use change are widely altering freshwater ecosystem functioning and there is an urgent need to understand how these broad stressor categories may interact in future. While much research has focused on mean temperature increases, climate change also involves increasing variability of both water temperature and flow regimes and increasing concentrations of atmospheric CO 2 , all with potential to alter stream invertebrate communities. Deposited fine sediment is a pervasive land-use stressor with widespread impacts on stream invertebrates. Sedimentation may be managed at the catchment scale; thus, uncovering interactions with these three key climate stressors may assist mitigation of future threats. This is the first experiment to investigate the individual and combined effects of enriched CO 2 , heatwaves, flow velocity variability, and fine sediment on realistic stream invertebrate communities. Using 128 mesocosms simulating small stony-bottomed streams in a 7-week experiment, we manipulated dissolved CO 2 (ambient; enriched), fine sediment (no sediment; 300 g dry sediment), temperature (ambient; two 7-day heatwaves), and flow velocity (constant; variable). All treatments changed community composition. CO 2 enrichment reduced abundances of Orthocladiinae and Chironominae and increased Copepoda abundance. Variable flow velocity had only positive effects on invertebrate abundances (7 of 13 common taxa and total abundance), in contrast to previous experiments showing negative impacts of reduced velocity. CO 2 was implicated in most stressor interactions found, with CO 2  × sediment interactions being most common. Communities forming under enriched CO 2 conditions in sediment-impacted mesocosms had ~20% fewer total invertebrates than those with either treatment alone. Copepoda abundances doubled in CO 2 -enriched mesocosms without sediment, whereas no CO 2 effect occurred in mesocosms with sediment. Our findings provide new insights into potential future impacts of climate change and land use in running freshwaters, in particular highlighting the potential for elevated CO 2 to interact with fine sediment deposition in unpredictable ways., (© 2024 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Importance: Point-of-sale food messaging can encourage healthier purchases, but no studies have directly compared multiple interventions in the field., Objective: To examine which of 4 food and beverage messages would increase healthier vending machine purchases., Design, Setting, and Participants: This randomized trial assessed 13 months (February 1, 2019, to February 29, 2020) of vending sales data from 267 machines and 1065 customer purchase assessments from vending machines on government property in Philadelphia, Pennsylvania. Data analysis was performed from March 5, 2020, to November 8, 2022., Interventions: Study interventions were 4 food and beverage messaging systems: (1) beverage tax posters encouraging healthy choices because of the Philadelphia tax on sweetened drinks; (2) green labels for healthy products; (3) traffic light labels: green (healthy), yellow (moderately healthy), or red (unhealthy); or (4) physical activity equivalent labels (minutes of activity to metabolize product calories)., Main Outcomes and Measures: Sales data were analyzed separately for beverages and snacks. The main outcomes analyzed at the transaction level were calories sold and the health status (using traffic light criteria) of each item sold. Additional outcomes were analyzed at the monthly machine level: total units sold, calories sold, and units of each health status sold. The customer purchase assessment outcome was calories purchased per vending trip., Results: Monthly sales data came from 150 beverage and 117 snack vending machines, whereas 1065 customers (558 [52%] male) contributed purchase assessment data. Traffic light labels led to a 30% decrease in the mean monthly number of unhealthy beverages sold (mean ratio [MR], 0.70; 95% CI, 0.55-0.88) compared with beverage tax posters. Physical activity labels led to a 34% (MR, 0.66; 95% CI, 0.51-0.87) reduction in the number of unhealthy beverages sold at the machine level and 35% (MR, 0.65; 95% CI, 0.50-0.86) reduction in mean calories sold. Traffic light labels also led to a 30-calorie reduction (b = -30.46; 95% CI, -49.36 to -11.56) per customer trip in the customer purchase analyses compared to physical activity labels. There were very few significant differences for snack machines., Conclusions and Relevance: In this 13-month randomized trial of 267 vending machines, the traffic light and physical activity labels encouraged healthier beverage purchases, but no change in snack sales, compared with a beverage tax poster. Corporations and governments should consider such labeling approaches to promote healthier beverage choices., Trial Registration: ClinicalTrials.gov Identifier: NCT06260176.

Plants and ecosystems worldwide are exposed to a wide range of chemical, physical, and biological factors of global change, many of which act concurrently. As bringing order to the array of factors is required in order to generate an enhanced understanding of simultaneous impacts, classification schemes have been developed. One such classification scheme is dedicated to capturing the different targets of global change factors along the ecological hierarchy. We build on this pioneering work, and refine the conceptual framework in several ways, focusing on plants and terrestrial systems: (i) we more strictly define the target level of the hierarchy, such that every factor typically has just one target level, and not many; (ii) we include effects above the level of the community, that is, there are effects also at the ecosystem scale that cannot be reduced to any level below this; (iii) we introduce the level of the landscape to capture certain land use change effects while abandoning the level below the individual. We discuss how effects can propagate along the levels of the ecological hierarchy, upwards and downwards, presenting opportunities for explaining non-additivity of effects of multiple factors. We hope that this updated conceptual framework will help inform the next generation of plant-focused global change experiments, specifically aimed at non-additivity of effects at the confluence of many factors., (© 2023 The Authors. The Plant Journal published by Society for Experimental Biology and John Wiley & Sons Ltd.)

Winter is a key driver of ecological processes in freshwater, marine and terrestrial ecosystems, particularly in higher latitudes. Species have evolved various adaptive strategies to cope with food limitations and the cold and dark wintertime. However, human-induced climate change and other anthropogenic stressors are impacting organisms in winter in unpredictable ways. In this paper, we show that global change experiments investigating multiple stressors have predominantly been conducted during summer months. However, effects of anthropogenic stressors sometimes differ between winter and other seasons, necessitating comprehensive investigations. Here, we outline a framework for understanding the different effects of anthropogenic stressors in winter compared to other seasons and discuss the primary mechanisms that will alter ecological responses of organisms (microbes, animals and plants). For instance, while the magnitude of some anthropogenic stressors can be greater in winter than in other seasons (e.g. some pollutants), others may alleviate natural winter stress (e.g. warmer temperatures). These changes can have immediate, delayed or carry-over effects on organisms during winter or later seasons. Interactions between stressors may also vary with season. We call for a renewed research direction focusing on multiple stressor effects on winter ecology and evolution to fully understand, and predict, how ecosystems will fare under changing winters. We also argue the importance of incorporating the interactions of anthropogenic stressors with winter into ecological risk assessments, management and conservation efforts., (© 2023 John Wiley & Sons Ltd.)

Introduction: Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions., Study Design: The study was an RCT., Setting/participants: An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020., Intervention: Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text)., Main Outcome Measures: Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies., Results: Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings., Conclusions: SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text., Trial Registration: This study is registered at www., Clinicaltrials: gov NCT03648138., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Men's low HPV vaccination uptake and HPV-related disease incidence are public health issues; gendered social-contextual factors likely play a role. In Study 1, college men (N = 130; M age  = 19.55; white = 58.1%) reported their social cognitions (male-referent descriptive norms and prototypes), self-reliance masculinity ideology, and vaccination intentions. In Study 2, college men (N = 106; M age  = 19.32; white = 61.3%) were randomly assigned to receive HPV vaccination information from a man or woman physician-avatar. Descriptive norms and favorable prototypes (bs ≥ .337; ps ≤ .016) were associated with higher HPV vaccination intentions. Men with higher self-reliance masculinity had higher HPV vaccination intentions with a man physician and when they perceived greater vaccination among men (ps ≤ .035). Men with higher self-reliance masculinity are more sensitive to gendered social-contextual effects in HPV vaccination decision-making. Gendered social-contextual factors should be integrated into public health interventions to increase college men's HPV vaccination uptake., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Flow sensors are often sensitive to the presence of volatile anesthetics. However, this sensitivity provides a unique opportunity to combine flow sensors of differing technological principles as an alternative to measuring volatile anesthetic gas concentration, particularly for austere settings. To determine the feasibility of flow sensor fusion for volatile anesthetic concentrations monitoring, eight flow sensors were tested with isoflurane, sevoflurane, and desflurane, ranging in concentrations from 0-4.5%, 0-3.5%, and 0-18%, respectively. Pairs of flow sensors were fit to the volatile anesthetic gas concentration with a leave-one-out cross-validation method to reduce the likelihood of overfitting. Bland-Altman was used for the final evaluation of sensor pair performance. Several sensor pairs yielded limits of agreement comparable to the rated accuracy of a commercial infrared spectrometer. The ultrasonic and orifice-plate flowmeters yielded the most combinations of viable sensor pairs for all three volatile anesthetic gases. Conclusion: Measuring volatile anesthetic gases using flow sensor fusion is a feasible low-cost, low-maintenance alternative to infrared spectroscopy. In this study, testing was done under steady-state conditions in 100% oxygen. Further testing is necessary to ensure sensor fusion performance under conditions that are more reflective of the clinical use case., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Global change encompasses many co-occurring anthropogenic stressors. Understanding the interactions between these multiple stressors, whether they be additive, antagonistic or synergistic, is critical for ecosystem managers when prioritizing which stressors to mitigate in the face of global change. While such interactions between stressors appear prevalent, it remains unclear if and how these interactions change over time, as the majority of multiple-stressor studies rarely span multiple generations of study organisms. Although meta-analyses have reported some intriguing temporal trends in stressor interactions, for example that synergism may take time to emerge, the mechanistic basis for such observations is unknown. In this study, by analysing data from an evolution experiment with the rotifer Brachionus calyciflorus (~35 generations and 31,320 observations), we show that adaptation to multiple stressors shifts stressor interactions towards synergism. We show that trade-offs, where populations cannot optimally perform multiple tasks (i.e. adapting to multiple stressors), generate this bias towards synergism. We also show that removal of stressors from evolved populations does not necessarily increase fitness and that there is variation in the evolutionary trajectories of populations that experienced the same stressor regimes. Our results highlight outstanding questions at the interface between evolution and global change biology, and illustrate the importance of considering rapid adaptation when managing or restoring ecosystems subjected to multiple stressors under global change., (© 2021 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Plant-soil systems are key for understanding the effects of factors of global change. Recent work has highlighted the general importance of considering the simultaneous incidence of some factors or stressors. To help mechanistically dissect the possible interactions of such factors, we here propose three broad groups of mechanisms that may generally lead to nonadditivity of responses within a plant-soil system: direct factor interactions (that is one factor directly changing another), within-plant information processing and crosstalk, and effects of factors on groups of soil biota interacting with plants. Interactions are also possible within and across these groups. Factor interactions are very likely to be present in experiments, especially when dealing with an increasing number of factors. Identifying the nature of such interactions will be essential for understanding and predicting global change impacts on plants and soil., (© 2021 The Authors. New Phytologist © 2021 New Phytologist Foundation.)

The aim of this study was to test the effects of CPAP on moderately sedated patients undergoing colonoscopy. Our hypothesis was that CPAP can reduce the incidence and duration of obstructive apnea and hemoglobin oxygen desaturation in patients undergoing procedural sedation for colonoscopy. Two groups of consenting adult patients scheduled to undergo routine colonoscopy procedures and sedated with propofol and fentanyl were monitored in this study: control and intervention. Patients in the intervention group were connected via a facemask to a ventilator that delivered supplemental oxygen (100%) through a standard air-cushion mask. The mask had a built-in leak to facilitate CO 2 clearance during CPAP. Patients in the control group received 2-10 L/min of oxygen via nasal cannula or non-rebreather mask. Subjects in the control group were collected in a prior study and used as historical controls. The primary outcome measures were the number of apneic events and the cumulative duration of apneic events. An apneic event was defined as a period longer than 10 s without respiration. The secondary outcome was the area under the curve (AUC) for the arterial oxygen saturation less than 90% versus time during sedative and analgesic administration (time (s) below threshold multiplied by percent below threshold). A desaturation event was defined as a period of time during which arterial oxygen saturation was less than 90%. 29 patients were enrolled in the intervention group and 156 patients were previously enrolled in the control group as part of an earlier study. The median number of apneic events in the control group was 7 compared to 0 in the intervention group. The intervention group experienced apnea less than 1% of the total procedure time compared to 17% in the control group (p < 0.001). There were no desaturation events observed in the 29 patients in the intervention group. In contrast, 27 out of 156 patients in the control group experienced a desaturation event. Average AUC of patients in the control group was 70%-s (time (s) * oxygen saturation below < 90%) (95% CI 32.34-108.60%) whereas the average AUC in intervention group patients was 0%-s (% time (s) * oxygen saturation < 90%) (95% CI 0-0%), p = 0.01. This preliminary study found that CPAP via a tight-fitting mask may be an effective tool to reduce the incidence and duration of obstructive apneic events as well as hemoglobin oxygen desaturation during lower endoscopy procedures that use propofol and fentanyl for sedation.Clinical Trial Registration ClinicalTrials.gov ID: NCT02623270. https://clinicaltrials.gov/ct2/show/NCT02623270 .

The rapid increase in online shopping and the extension of online food purchase and delivery services to federal nutrition program participants highlight the need for a conceptual framework capturing the influence of online food retail environments on consumer behaviors. This study aims to develop such a conceptual framework. To achieve this, mixed methods were used, including: (1) a literature review and development of an initial framework; (2) key informant interviews; (3) pilot testing and refinement of the draft framework; and (4) a group discussion with experts to establish content validity. The resulting framework captures both consumer- and retailer-level influences across the entire shopping journey, as well as the broader social, community, and policy context. It identifies important factors such as consumer demographic characteristics, preferences, past behaviors, and retailer policies and practices. The framework also emphasizes the dynamic nature of personalized marketing by retailers and customizable website content, and captures equity and transparency in retailer policies and practices. The framework draws from multiple disciplines, providing a foundation for understanding the impact of online food retail on dietary behaviors. It can be utilized to inform public health interventions, retailer practices, and governmental policies for creating healthy and equitable online food retail environments.

Performing uncertainty quantification (UQ) and sensitivity analysis (SA) is vital when developing a patient-specific physiological model because it can quantify model output uncertainty and estimate the effect of each of the model's input parameters on the mathematical model. By providing this information, UQ and SA act as diagnostic tools to evaluate model fidelity and compare model characteristics with expert knowledge and real world observation. Computational efficiency is an important part of UQ and SA methods and thus optimization is an active area of research. In this work, we investigate a new efficient sampling method for least-squares polynomial approximation, weighted approximate Fekete points (WAFP). We analyze the performance of this method by demonstrating its utility in stochastic analysis of a cardiovascular model that estimates changes in oxyhemoglobin saturation response. Polynomial chaos (PC) expansion using WAFP produced results similar to the more standard Monte Carlo in quantifying uncertainty and identifying the most influential model inputs (including input interactions) when modeling oxyhemoglobin saturation, PC expansion using WAFP was far more efficient. These findings show the usefulness of using WAFP based PC expansion to quantify uncertainty and analyze sensitivity of a oxyhemoglobin dissociation response model. Applying these techniques could help analyze the fidelity of other relevant models in preparation for clinical application., (© 2020 John Wiley & Sons Ltd.)

Background: People with autism spectrum disorder (ASD) face many psychosocial challenges throughout life, highlighting the need for programs and resources promoting psychosocial wellbeing. Indigenous peoples with ASD and/or other neurodevelopmental disorders must overcome cultural and social barriers to access such supports. This study aimed to identify psychosocial programs and resources developed world-wide for this population by systematically reviewing research evaluating programs aiming to promote the psychosocial wellbeing of this population and/or their caregivers; and collating and reviewing resources developed to promote their psychosocial wellbeing., Methods: Searches were last conducted in December 2019. The systematic review searched 28 electronic databases, and 25 electronic databases were searched for resources promoting psychosocial wellbeing. Additional published and unpublished studies were identified from relevant reviews, authors of eligible articles, and experts working in Indigenous Health. Articles and resources were screened for inclusion using pre-defined criteria. Articles included in the systematic review were assessed for quality using the Mixed Methods Assessment Tool. The diversity and paucity of outcomes reported precluded pooling of study findings for meta-analysis., Results: Seven articles situated in the USA (2), Canada (3) and Australia (2); and eleven resources developed in Australia (9), Canada (1) and New Zealand (1) met inclusion criteria. All articles showed some promising findings for improving psychosocial wellbeing for Indigenous children with ASD and/or another neurodevelopmental disorder, and 5 of 7 evaluated the cultural adaptation of an existing evidence-based program for an Indigenous population. However, methodological quality was moderate or low (57% and 43% of articles respectively) and no studies had adult participants. The psychosocial wellbeing supports provided by the 11 resources included psychoeducation, community support, and services/workshops., Conclusions: Despite the paucity of research and resources found, important exemplars demonstrate that existing programs can be adapted to support Indigenous people with ASD and other neurodevelopmental disorders. While future policy should endeavour to facilitate Indigenous people's access to support services, and encourage researchers to develop and evaluate programs promoting psychosocial wellbeing for this population, given complexities of designing and evaluating new programs, careful and appropriate cultural adaptations of existing evidence-based programs would increase feasibility of ongoing research without compromising outcomes.

Anthropogenic environmental changes, or 'stressors', increasingly threaten biodiversity and ecosystem functioning worldwide. Multiple-stressor research is a rapidly expanding field of science that seeks to understand and ultimately predict the interactions between stressors. Reviews and meta-analyses of the primary scientific literature have largely been specific to either freshwater, marine or terrestrial ecology, or ecotoxicology. In this cross-disciplinary study, we review the state of knowledge within and among these disciplines to highlight commonality and division in multiple-stressor research. Our review goes beyond a description of previous research by using quantitative bibliometric analysis to identify the division between disciplines and link previously disconnected research communities. Towards a unified research framework, we discuss the shared goal of increased realism through both ecological and temporal complexity, with the overarching aim of improving predictive power. In a rapidly changing world, advancing our understanding of the cumulative ecological impacts of multiple stressors is critical for biodiversity conservation and ecosystem management. Identifying and overcoming the barriers to interdisciplinary knowledge exchange is necessary in rising to this challenge. Division between ecosystem types and disciplines is largely a human creation. Species and stressors cross these borders and so should the scientists who study them.

Background: Opioid-induced respiratory depression (OIRD) is traditionally recognized by assessment of respiratory rate, arterial oxygen saturation, end-tidal CO2, and mental status. Although an irregular or ataxic breathing pattern is widely recognized as a manifestation of opioid effects, there is no standardized method for assessing ataxic breathing severity. The purpose of this study was to explore using a machine-learning algorithm for quantifying the severity of opioid-induced ataxic breathing. We hypothesized that domain experts would have high interrater agreement with each other and that a machine-learning algorithm would have high interrater agreement with the domain experts for ataxic breathing severity assessment., Methods: We administered target-controlled infusions of propofol and remifentanil to 26 healthy volunteers to simulate light sleep and OIRD. Respiration data were collected from respiratory inductance plethysmography (RIP) bands and an intranasal pressure transducer. Three domain experts quantified the severity of ataxic breathing in accordance with a visual scoring template. The Krippendorff alpha, which reports the extent of interrater agreement among N raters, was used to assess agreement among the 3 domain experts. A multiclass support vector machine (SVM) was trained on a subset of the domain expert-labeled data and then used to quantify ataxic breathing severity on the remaining data. The Vanbelle kappa was used to assess the interrater agreement of the machine-learning algorithm with the grouped domain experts. The Vanbelle kappa expands on the Krippendorff alpha by isolating a single rater-in this case, the machine-learning algorithm-and comparing it to a group of raters. Acceptance criteria for both statistical measures were set at >0.8. The SVM was trained and tested using 2 sensor inputs for the breath marks: RIP and intranasal pressure., Results: Krippendorff alpha was 0.93 (95% confidence interval [CI], 0.91-0.95) for the 3 domain experts. Vanbelle kappa was 0.98 (95% CI, 0.96-0.99) for the RIP SVM and 0.96 (0.92-0.98) for the intranasal pressure SVM compared to the domain experts., Conclusions: We concluded it may be feasible for a machine-learning algorithm to quantify ataxic breathing severity in a manner consistent with a panel of domain experts. This methodology may be helpful in conjunction with traditional measures to identify patients experiencing OIRD.

The oxyhemoglobin dissociation curve describes the relationship between the partial pressure of oxygen and the percent of hemoglobin saturated with oxygen and varies with chemical and physical factors that differ for every patient. If variability could be determined, patient-specific oxygen therapy could be administered. We have developed a procedure for characterizing variations in the oxygen dissociation curve. The purpose of this study was to validate this procedure in surgical patients. The procedure uses an automated system to alter oxygen therapy during surgery, within safe operational levels, and fit to Hill's equation non-invasive measurements of end-tidal oxygen and peripheral pulse oxygen saturation. The best-fit parameters for the Hill equation, estimated by iterative least squares, provide an apparent dissociation curve, meaningful of the patient-specific pulse oximeter response. Thirty-nine patients participated in this study. Using patient-specific parameter values increases correlation when compared with standard values. The procedure improved the model fit of patient saturation values significantly in 19 patients. This paper has demonstrated a procedure for determining patient-specific pulse oximeter response. This procedure determined best-fit parameters resulting in a significantly improved fit when compared with standard values. These best-fit parameters increased the coefficient of determination R 2 in all cases. Graphical Abstract This patient-specific procedure improves fit significantly compared to standard estimates.

Background: Supplemental oxygen is administered during procedural sedation to prevent hypoxemia. Continuous flow oxygen, the most widespread method, is generally adequate but distorts capnography. Pulsed flow oxygen is novel and ideally will not distort capnography. We have developed a prototype oxygen administration system designed to try to facilitate end-tidal carbon dioxide (ETCO2) measurement. We conducted a volunteer study (ClinicalTrials.gov, NCT02886312) to determine how much nasal ETCO2 measurements vary with oxygen flow rate. We also conducted a clinical study (NCT02962570) to determine the median difference and limits of agreement between ETCO2 measurements made with and without administering oxygen., Methods: Both studies were conducted at the University of Utah and participants acted as their own control. Inclusion criteria were age 18 years and older with an American Society of Anesthesiologists physical status of I-III. Exclusion criteria included acute respiratory distress syndrome, pneumonia, lung or cardiovascular disease, nasal/bronchial congestion, pregnancy, oxygen saturation measured by pulse oximetry <93%, and a procedure scheduled for <20 minutes. For the volunteer study, pulsed and continuous flow was administered at rates from 2 to 10 L/min using a single sequence of technique and flow. The median absolute deviation from the median value was analyzed for the primary outcome of ETCO2. For the clinical study, ETCO2 measurements (the primary outcome) were collected while administering pulsed and continuous flow at rates between 1 and 5 L/min and were compared to measurements without oxygen flow. Due to institutional review board requirements for patient safety, this study was not randomized. After completing the study, measurements with and without administering oxygen were analyzed to determine median differences and 95% limits of agreement for each administration technique., Results: Thirty volunteers and 60 patients participated in these studies which ended after enrolling the predetermined number of participants. In volunteers, the median absolute deviation for ETCO2 measurements made while administering pulsed flow oxygen (0.89; 25%-75% quantiles: 0.3-1.2) was smaller than while administering continuous flow oxygen (3.93; 25%-75% quantiles: 2.2-6.2). In sedated patients, the median difference was larger during continuous flow oxygen (-6.8 mm Hg; 25%-75% quantiles: -12.5 to -2.1) than during pulsed flow oxygen (0.1 mm Hg; 25%-75% quantiles: -0.5 to 1.5). The 95% limits of agreement were also narrower during pulsed flow oxygen (-2.4 to 4.5 vs -30.5 to 2.4 mm Hg)., Conclusions: We have shown that nasal ETCO2 measurements while administering pulsed flow have little deviation and agree well with measurements made without administering oxygen. We have also demonstrated that ETCO2 measurements during continuous flow oxygen have large deviation and wide limits of agreement when compared with measurements made without administering oxygen.

This paper describes a method for estimating the oxygen enhanced end-tidal fraction of oxygen (F et O e ), the end-tidal fraction of oxygen (F et O 2 ) that is raised by administering supplemental oxygen. The paper has two purposes: the first is to evaluate the method's accuracy on the bench and in volunteers; the second purpose is to demonstrate how to apply the method to compare two techniques of oxygen administration. The method estimates F et O e by analyzing expired oxygen as oxygen washes out of the lung. The method for estimating F et O e was first validated using a bench simulation in which tracheal oxygen was measured directly. Then it was evaluated in 30 healthy volunteers and compared to the bench simulation. Bland-Altman analysis compared calculated and observed F et O e /F et O 2 measurements. After the method was evaluated, it was implemented to compare the F et O e obtained when administering oxygen using two different techniques (pulsed and continuous flow). A total of eighteen breath washout conditions were evaluated on the bench. F et O e estimates and tracheal F et O 2 had a mean difference of - 0.016 FO 2 with 95% limits of agreement from - 0.048 to 0.016 FO 2 . Thirteen breath washouts per volunteer were analyzed. Extrapolated and observed F et O 2 had a mean difference of - 0.001 FO 2 with 95% limits of agreement from - 0.006 to 0.004 FO 2 . Pulsed flow oxygen (PFO) achieved the same F et O e values as continuous flow oxygen (CFO) using 32.1% ± 2.27% (mean ± SD) of the CFO rate. This paper has demonstrated that the method estimates F et O 2 enhanced by administering supplemental oxygen with clinically insignificant differences. This paper has also shown that PFO can obtain F et O 2 similar to CFO using approximately one-third of the oxygen volume. After evaluating this method, we conclude that the method provides useful estimates of nasal F et O 2 enhanced by supplemental oxygen administration.

Drug-induced respiratory depression is a major cause of serious adverse events. Adequate oxygenation is very important during sedated esophagogastroduodenoscopy (EGD). Nasal breathing often shifts to oral breathing during open mouth EGD. A mandibular advancement bite block was developed for EGD using computer-assisted design and three-dimensional printing techniques. The mandible is advanced when using this bite block to facilitate airway opening. The device is composed of an oxygen inlet with one opening directed towards the nostril and another opening directed towards the oral cavity. The aim of this bench study was to compare the inspired oxygen concentration (FiO 2 ) provided by the different nasal cannulas, masks, and bite blocks commonly used in sedated EGD. A manikin head was connected to one side of a two-compartment lung model by a 7.0 mm endotracheal tube with its opening in the nasopharyngeal position. The other compartment was driven by a ventilator to mimic "patient" inspiratory effort. Using this spontaneously breathing lung model, we evaluated five nasal cannulas, two face masks, and four new oral bite blocks at different oxygen flow rates and different mouth opening sizes. The respiratory rate was set at 12/min with a tidal volume of 500 mL and 8/min with a tidal volume of 300 mL. Several Pneuflo resistors of different sizes were used in the mouth of the manikin head to generate different degrees of mouth opening. FiO 2 was evaluated continuously via the endotracheal tube. All parameters were evaluated using a Datex anesthesia monitoring system. The mandibular advancement bite block provided the highest FiO 2 under the same supplemental oxygen flow. The FiO 2 was higher for devices with oxygen flow provided via an oral bite block than that provided via the nasal route. Under the same supplemental oxygen flow, the tidal volume and respiratory rate also played an important role in the FiO 2 . A low respiratory rate with a smaller tidal volume has a relative high FiO 2 . The ratio of nasal to oral breathing played an important role in the FiO 2 under hypoventilation but less role under normal ventilation. Bite blocks deliver a higher FiO 2 during EGD. The ratio of nasal to oral breathing, supplemental oxygen flow, tidal volume, and respiratory rate influenced the FiO 2 in most of the supplemental oxygen devices tested, which are often used for conscious sedation in patients undergoing EGD and colonoscopy.

High depression rates for adolescents with autism indicate a need for a comprehensive prevention approach. Parents can promote parent-child factors that buffer adolescents from depression. However, parenting adolescents with autism presents challenges which can diminish parental self-efficacy and mental wellbeing with potential negative sequelae for their adolescents. This proof-of-concept study investigated the value of adding a strength-focused parenting intervention to a depression-prevention intervention for adolescents with autism. A Consensual Qualitative Research framework analysed 15 parents' intervention experience. Parents reported that feeling isolated and unsupported by existing services motivated their participation, and they valued interacting with other parent participants. They also reported that the program enhanced wellbeing and parenting efficacy, reduced isolation, increased ability to parent calmly, and improved parent-adolescent relationships.

Despite increased depression in adolescents with Autism Spectrum Disorder (ASD), effective prevention approaches for this population are limited. A mixed methods pilot randomised controlled trial (N = 29) of the evidence-based Resourceful Adolescent Program-Autism Spectrum Disorder (RAP-A-ASD) designed to prevent depression was conducted in schools with adolescents with ASD in years 6 and 7. Quantitative results showed significant intervention effects on parent reports of adolescent coping self-efficacy (maintained at 6 month follow-up) but no effect on depressive symptoms or mental health. Qualitative outcomes reflected perceived improvements from the intervention for adolescents' coping self-efficacy, self-confidence, social skills, and affect regulation. Converging results remain encouraging given this population's difficulties coping with adversity, managing emotions and interacting socially which strongly influence developmental outcomes.

Background: Research has shown that increased breathing frequency during cardiopulmonary resuscitation is inversely correlated with systolic blood pressure. Rescuers often hyperventilate during cardiopulmonary resuscitation (CPR). Current American Heart Association advanced cardiac life support recommends a ventilation rate of 8-10 breaths/min. We hypothesized that a small, turbine-driven ventilator would allow rescuers to adhere more closely to advanced cardiac life support (ACLS) guidelines., Methods: Twenty-four ACLS-certified health-care professionals were paired into groups of 2. Each team performed 4 randomized rounds of 2-min cycles of CPR on an intubated mannikin, with individuals altering between compressions and breaths. Two rounds of CPR were performed with a self-inflating bag, and 2 rounds were with the ventilator. The ventilator was set to deliver 8 breaths/min, pressure limit 22 cm H 2 O. Frequency, tidal volume (V T ), peak inspiratory pressure, and compression interruptions (hands-off time) were recorded. Data were analyzed with a linear mixed model and Welch 2-sample t test., Results: The median (interquartile range [IQR]) frequency with the ventilator was 7.98 (7.98-7.99) breaths/min. Median (IQR) frequency with the self-inflating bag was 9.5 (8.2-10.7) breaths/min. Median (IQR) ventilator V T was 0.5 (0.5-0.5) L. Median (IQR) self-inflating bag V T was 0.6 (0.5-0.7) L. Median (IQR) ventilator peak inspiratory pressure was 22 (22-22) cm H 2 O. Median (IQR) self-inflating bag peak inspiratory pressure was 30 (27-35) cm H 2 O. Mean ± SD hands-off times for ventilator and self-inflating bag were 5.25 ± 2.11 and 6.41 ± 1.45 s, respectively., Conclusions: When compared with a ventilator, volunteers ventilated with a self-inflating bag within ACLS guidelines. However, volunteers ventilated with increased variation, at higher V T levels, and at higher peak pressures with the self-inflating bag. Hands-off time was also significantly lower with the ventilator. (ClinicalTrials.gov registration NCT02743299.)., (Copyright © 2017 by Daedalus Enterprises.)

Understanding the role that therapists play in psychotherapy outcome, and the contribution to outcome made by individual therapist differences has implications for service delivery and training of therapists. In this study we used a novel approach to estimate the magnitude of the therapist contribution overall and the effect of individual therapist differences. We conducted a meta-analysis of studies in which participants were randomised to receive the same treatment either through self-help or through a therapist. We identified a total of 15 studies (commencement N = 910; completion N = 723) meeting inclusion criteria. We found no difference in treatment completion rate and broad equivalence of treatment outcomes for participants treated through self-help and participants treated through a therapist. Also, contrary to our expectations, we found that the variability of outcomes was broadly equivalent, suggesting that differences in efficacy of individual therapists were not sufficient to make therapy outcomes more variable when a therapist was involved. Overall, the findings suggest that self-help, with minimal therapist input, has considerable potential as a first-line intervention. The findings did not suggest that individual differences between therapists play a major role in psychotherapy outcome.

Despite an increased risk of mental health problems in adolescents with autism spectrum disorder (ASD), there is limited research on effective prevention approaches for this population. Funded by the Cooperative Research Centre for Living with Autism, a theoretically and empirically supported school-based preventative model has been developed to alter the negative trajectory and promote wellbeing and positive mental health in adolescents with ASD. This conceptual paper provides the rationale, theoretical, empirical and methodological framework of a multilayered intervention targeting the school, parents and adolescents on the spectrum. Two important interrelated protective factors have been identified in community adolescent samples, namely the sense of belonging (connectedness) to school and the capacity for self and affect regulation in the face of stress (i.e. resilience). We describe how a confluence of theories from social psychology, developmental psychology and family systems theory, along with empirical evidence (including emerging neurobiological evidence), supports the interrelationships between these protective factors and many indices of wellbeing. However, the characteristics of ASD (including social and communication difficulties, and frequently difficulties with changes and transitions, and diminished optimism and self-esteem) impair access to these vital protective factors. The paper describes how evidence-based interventions at the school level for promoting inclusive schools (using the Index for Inclusion) and interventions for adolescents and parents to promote resilience and belonging [using the Resourceful Adolescent Program (RAP)] are adapted and integrated for adolescents with ASD. This multisite proof-of-concept study will confirm whether this multilevel school-based intervention is promising, feasible and sustainable.

Background: Gastric reflux leading to pulmonary aspiration is a frequent event in mechanically ventilated, gastric-fed patients, which can lead to ventilator-associated complications and pneumonia., Objectives: The objectives of this study were to determine the association between gastric reflux and aspiration using the presence of pepsin in oral or tracheal secretions as a marker of reflux or aspiration and to determine the association between the pH (range, 0-14) and the presence of pepsin in oral secretions., Methods: A descriptive correlational study was conducted in mechanically ventilated surgical or medical patients receiving gastric tube feedings. Oral secretions were suctioned hourly and tracheal secretions every 2 to 3 hours for 12-hour periods over 1 to 2 days in 15 patients., Results: There were 142 paired samples of oral tracheal secretions. A majority of samples (60%) had the same results, with 32% both pepsin-positive and 27% both pepsin-negative. The range of pH measurements was 4 to 8, with a mean of 6.3 ± 0.05. Ninety oral specimens had a pH of 4 to 6. Forty-seven of the oral specimens with pH measures between 4 and 6 (52%) were pepsin-positive. The correlation of pH percent pepsin-positive oral secretions was not significant., Conclusion: Aspiration events were more frequent than reflux events. Measurement of actual pepsin concentration to detect new reflux and aspiration events is recommended in future studies. Bedside pH measures of oral secretions are not a valid marker of gastric reflux.

Healthy behaviour, such as smoking cessation and adherence to prescribed medications, mitigates illness risk factors but health behaviour change can be challenging. Mobile phone short-message service (SMS) messages are increasingly used to deliver interventions designed to enhance healthy behaviour. This meta-analysis used a random-effects model to synthesise 38 randomised controlled trials that investigated the efficacy of SMS messages to enhance healthy behaviour. Participants (N = 19,641) lived in developed and developing countries and were diverse with respect to age, ethnicity, socioeconomic background and health behaviours targeted for change. SMS messages had a small, positive, significant effect (g = 0.291) on a broad range of healthy behaviour. This effect was maximised when multiple SMS messages per day were used (g = 0.395) compared to using lower frequencies (daily, multiple per week and once-off) (g = 0.244). The low heterogeneity in this meta-analysis (I (2) = 38.619) supports reporting a summary effect size and implies that the effect of SMS messaging is robust, regardless of population characteristics or healthy behaviour targeted. SMS messaging is a simple, cost-effective intervention that can be automated and can reach any mobile phone owner. While the effect size is small, potential health benefits are well worth achieving.

Background: Undetected apnea can lead to severe hypoxia, bradycardia, and cardiac arrest. Tracheal sounds entropy has been proved to be a robust method for estimating respiratory flow, thus maybe a more reliable way to detect obstructive and central apnea during sedation., Methods: A secondary analysis of a previous pharmacodynamics study was conducted. Twenty volunteers received propofol and remifentinal until they became unresponsive to the insertion of a bougie into the esophagus. Respiratory flow rate and tracheal sounds were recorded using a pneumotachometer and a microphone. The logarithm of the tracheal sound Shannon entropy (Log-E) was calculated to estimate flow rate. An adaptive Log-E threshold was used to distinguish between the presence of normal breath and apnea. Apnea detected from tracheal sounds was compared to the apnea detected from respiratory flow rate., Results: The volunteers stopped breathing for 15 s or longer (apnea) 322 times during the 12.9-h study. Apnea was correctly detected 310 times from both the tracheal sounds and the respiratory flow. Periods of apnea were not detected by the tracheal sounds 12 times. The absence of tracheal sounds was falsely detected as apnea 89 times. Normal breathing was detected correctly 1,196 times. The acoustic method detected obstructive and central apnea in sedated volunteers with 95% sensitivity and 92% specificity., Conclusions: We found that the entropy of the acoustic signal from a microphone placed over the trachea may reliably provide an early warning of the onset of obstructive and central apnea in volunteers under sedation.

Thromboxane A(2) (TxA(2)) is an arachidonic acid metabolite that stimulates platelet aggregation and vasoconstriction when released from platelets and other cell types during tissue trauma. More recent research has demonstrated that TxA(2) can also stimulate vagal and spinal sensory nerves. The purpose of this study was twofold. One, we compared the expression of the TxA(2) receptor (TxA2R) in neurons from two sensory ganglia: the nodose ganglion (NG) containing cell bodies of vagal afferent nerves and the thoracic dorsal root ganglion (DRG) containing cell bodies of spinal afferent nerves. Two, we determined if TxA2R co-localizes with mRNA for the nociceptive marker, TRPV1, which is the receptor for the noxious substance capsaicin. We found a greater percentage of neurons in the NG that are positive for TxA2R expression than in the DRG. We also found that there was no correlation of expression of TxA2R with TRPV1. These data suggest that while TxA2R is expressed in both vagal and spinal neurons, TxA(2) may elicit stronger vagal or parasympathetic reflexes in the rabbit when released during tissue trauma depending on the location of release. Our data also indicate that TxA(2) is likely to stimulate both nociceptive and non-nociceptive neurons thereby broadening the types of neurons and reflexes that it may excite., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: There is a need for a bedside functional residual capacity (FRC) measurement method that performs well in intensive care patients during many modes of ventilation including controlled, assisted, spontaneous, and mixed. We developed a modified multiple breath nitrogen washout method for FRC measurement that relies on end-tidal gas fractions and alveolar tidal volume measurements as inputs but does not require the traditional measurements of volume of nitrogen or oxygen. Using end-tidal measurements, not volume, reduces errors from signal synchronization. This study was designed to assess the accuracy, precision, and repeatability of the proposed FRC system in subjects with variable ventilation patterns including some spontaneous effort., Methods: The accuracy and precision of measurements were assessed by comparing the novel N₂ washout FRC values to the gold standard, body plethysmography, in 20 spontaneously breathing volunteers. Repeatability was assessed by comparing subsequent measurements in 20 intensive care patients whose lungs were under controlled and assisted mechanical ventilation., Results: Compared with body plethysmography, the accuracy (mean bias) of the novel method was -0.004 litre and precision [1 standard deviation (sd)] was 0.209 litre [mean (sd)] [-0.1 (5.9)% of body plethysmography]. The difference between repeated measurements was 0.009 (0.15) litre [mean (sd)] [0.4 (6.4)%]. The coefficient of repeatability was 0.31 litre (12.7%)., Conclusions: The modified multiple breath nitrogen washout method for FRC measurement provides improved precision and equivalent accuracy and repeatability compared with existing methods during ventilation with variable ventilation patterns. Further study of the novel N₂ washout method is needed.

In this article, the challenges of simultaneous respiratory gas concentration and flow measurements in a breathing circuit are reviewed. The tradeoffs that were considered in the development of a clinically useful on-airway combination CO(2)/flow sensor are discussed as well as the applications enabled by this on-airway combination CO(2)/flow sensor.

We have recently reported that left atrial injections of the thromboxane A(2) (TXA(2)) mimetic, (5Z)-7-[(1R,4S,5S,6R)-6-[(1E,3S)-3-hydroxy-1-octenyl]-2 -oxabicyclo[2.2.1]hept-5-yl]-5-heptenoic acid (U46619), induced ventricular arrhythmias in the anesthetized rabbit. Data from this study led us to hypothesize that TXA(2) may be inducing direct actions on the myocardium to induce these arrhythmias. The aim of this study was to further elucidate the mechanism responsible for these arrhythmias. We report that TXA(2)R is expressed at both the gene and protein levels in atrial and ventricular samples of adult rabbits. In addition, TXA(2)R mRNA was identified in single, isolated ventricular cardiac myocytes. Furthermore, treatment of isolated cardiac myocytes with U46619 increased intracellular calcium in a dose-dependent manner and these increases were blocked by the specific TXA(2)R antagonist, 7-(3-((2-((phenylamino)carbonyl)hydrazino)methyl)-7-oxabicyclo(2.2.1)hept-2-yl)-5-heptenoic acid (SQ29548). Pretreatment of myocytes with an inhibitor of inositol trisphosphate (IP(3)) formation, gentamicin, or with an inhibitor of IP(3) receptors, 2-aminoethoxydiphenylborate (2-APB), blocked the increase in intracellular calcium. In vivo pretreatment of anesthetized rabbits with either gentamicin or 2-APB subsequently inhibited the formation of ventricular arrhythmias elicited by U46619. These data support the hypothesis that TXA(2) can induce arrhythmias via a direct action on cardiac myocytes. Furthermore, these arrhythmogenic actions were blocked by inhibitors of the IP(3) pathway. In summary, this study provides novel evidence for direct TXA(2)-induced cardiac arrhythmias and provides a rationale for IP(3) as a potential target for the treatment of TXA(2)-mediated arrhythmias.

Background: Several techniques for measuring the functional residual capacity (FRC) of the lungs in mechanically ventilated patients have been proposed, each of which is based on either nitrogen wash-out or dilution of tracer gases. These methods are expensive, difficult, time-consuming, impractical, or require an intolerably large change in the fraction of inspired oxygen. We propose a CO(2) wash-in method that allows automatic and continual FRC measurement in mechanically ventilated patients., Methods: We measured FRC with a CO(2) partial rebreathing technique, first in a mechanical lung analog, and then in mechanically ventilated animals, before, during, and subsequent to an acute lung injury induced with oleic acid. We compared FRC measurements from partial CO(2) rebreathing to measurements from a nitrogen wash-out reference method. Using an approved animal protocol, general anesthesia was induced and maintained with propofol in 6 swine (38.8-50.8 kg). A partial CO(2) rebreathing monitor was placed in the breathing circuit between the endotracheal tube and the Y-piece. The partial CO(2) rebreathing signal obtained from the monitor was used to calculate FRC. FRC was also measured with a nitrogen wash-out measurement technique. In the animal studies we collected data from healthy lungs, and then subsequent to a lung injury that simulated the conditions of acute lung injury/acute respiratory distress syndrome. The injury was created by intravenously infusing 0.09 mL/kg of oleic acid over a 15-min period. At each stage of the experiment, the positive end-expiratory pressure (PEEP) was set to 0, 5, 10, or 15 cm H(2)O. At each PEEP level we compared the average of 3 CO(2) rebreathing FRC measurements to the average of 3 nitrogen wash-out reference measurements. We also tested the FRC measurement system with a mechanical test lung in which the true FRC could be directly measured., Results: The squared correlation for the linear regression between CO(2) rebreathing and nitrogen wash-out measurements in the animals was r(2) = 0.89 (n = 50). The average error of the CO(2) wash-out system was -87 mL and the limits of agreement were+/- 263 mL. In the mechanical test lung, the average error of the FRC measured via the CO(2) wash-in system was 37 mL, and the limits of agreement were +/- 103 mL, which was equivalent to 1.7% of the true FRC. The squared correlation was r(2) = 0.96., Conclusion: These results indicate that FRC measurement via CO(2) rebreathing can reliably detect an FRC decrease during lung injury and can reflect the response of the FRC to treatment with PEEP.