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Use of magnetic resonance imaging (MRI) as a tool to aid in neuroprognostication after cardiac arrest (CA) has been described, yet details of specific indications, timing, and sequences are unknown. We aim to define the current practices in use of brain MRI in prognostication after pediatric CA.A survey was distributed to pediatric institutions participating in three international studies. Survey questions related to center demographics, clinical practice patterns of MRI after CA, neuroimaging resources, and details regarding MRI decision support.Response rate was 31% (44 of 143). Thirty-four percent (15 of 44) of centers have a clinical pathway informing the use of MRI after CA. Fifty percent (22 of 44) of respondents reported that an MRI is obtained in nearly all patients with CA, and 32% (14 of 44) obtain an MRI in those who do not return to baseline neurological status. Poor neurological examination was reported as the most common factor (91% [40 of 44]) determining the timing of the MRI. Conventional sequences (T1, T2, fluid-attenuated inversion recovery, and diffusion-weighted imaging/apparent diffusion coefficient) are routinely used at greater than 97% of centers. Use of advanced imaging techniques (magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI) were reported by less than half of centers.Conventional brain MRI is a common practice for prognostication after CA. Advanced imaging techniques are used infrequently. The lack of standardized clinical pathways and variability in reported practices support a need for higher-quality evidence regarding the indications, timing, and acquisition protocols of clinical MRI studies.

BACKGROUND AND PURPOSE: The incretin hormone, gastric inhibitory peptide/glucose-dependent insulinotropic polypeptide (GIP), secreted by the enteroendocrine K-cells in the proximal intestine, may regulate lipid metabolism and adiposity, but its exact role in these processes is unclear.EXPERIMENTAL APPROACH: We characterized in vitro and in vivo antagonistic properties of a novel GIP analogue, mGIPAnt-1. We further assessed the in vivo pharmacokinetic profile of this antagonist, as well as its ability to affect high-fat diet (HFD)-induced body weight gain in ovariectomised mice during an 8-week treatment period.KEY RESULTS: mGIPAnt-1 showed competitive antagonistic properties to the GIP receptor in vitro as it inhibited GIP-induced cAMP accumulation in COS-7 cells. Furthermore, mGIPAnt-1 was capable of inhibiting GIP-induced glucoregulatory and insulinotropic effects in vivo and has a favourable pharmacokinetic profile with a half-life of 7.2 h in C57Bl6 female mice. Finally, sub-chronic treatment with mGIPAnt-1 in ovariectomised HFD mice resulted in a reduction of body weight and fat mass.CONCLUSION AND IMPLICATIONS: mGIPAnt-1 successfully inhibited acute GIP-induced effects in vitro and in vivo and sub-chronically induces resistance to HFD-induced weight gain in ovariectomised mice. Our results support the development of GIP antagonists for the therapy of obesity.

Sleep apnea is a common and strongly under-diagnosed severe sleep-related respiratory disorder with periods of disrupted or reduced breathing during sleep. To diagnose sleep apnea, sleep data are collected with either polysomnography or polygraphy and scored by a sleep expert. We investigate in this work the use of supervised machine learning to automate the analysis of polygraphy data from the A3 study containing more than 7,400 hours of sleep monitoring data from 579 patients. We conduct a systematic comparative study of classification performance and resource use with different combinations of 27 classifiers and four sleep signals. The classifiers achieve up to 0.8941 accuracy (kappa: 0.7877) when using all four signal types simultaneously and up to 0.8543 accuracy (kappa: 0.7080) with only one signal, i.e., oxygen saturation. Methods based on deep learning outperform other methods by a large margin. All deep learning methods achieve nearly the same maximum classification performance even when they have very different architectures and sizes. When jointly accounting for classification performance, resource consumption and the ability to achieve with less training data high classification performance, we find that convolutional neural networks substantially outperform the other classifiers.

Objective To describe a case of a patient who developed psychosis after ingestion of Vertigoheel for treatment of dizziness. Case Summary A 28-year-old male with no psychiatric history presented with 5 days of worsening depression and psychosis. He denied current use of prescription medications, alcohol, or illicit substances. Approximately 2 weeks prior, while visiting family in Germany, he developed dizziness. A provider in Germany prescribed Vertigoheel, 1 tablet to be taken every hour until symptom improvement. This did not improve his dizziness but did cause him to feel as if he were “in a dream.” He stopped taking the medication after 2 days but continued to feel amotivated with decreased appetite and insomnia. Several days later, he developed ego-dystonic auditory hallucinations. He returned to the United States; was admitted to an inpatient psychiatric unit for 4 days; and given olanzapine 5 mg at bedtime, lorazepam 1 mg every evening, and melatonin 6 mg every evening. He experienced gradual improvement in symptoms and was discharged with olanzapine 5 mg daily and outpatient follow-up. Discussion Vertigoheel is a homeopathic preparation containing ambra grisea, Cocculus indicus, Conium maculatum, and petroleum. Psychosis was not reported in any of the randomized controlled trials evaluating the use of Vertigoheel for treatment of vertigo. A literature search revealed no published reports of psychosis as a result of administration of any components of Vertigoheel. Conclusion A possible causal relationship was observed between the homeopathic supplement Vertigoheel and an acute episode of psychosis in a young male patient with no comorbidities.

Balanced reciprocal translocation carriers are at increased risk of producing gametes with unbalanced forms of the translocation leading to miscarriage, fetal anomalies, and birth defects. We sought to determine if genome-wide cell-free DNA based noninvasive prenatal screening (gw-NIPS) could provide an alternative to prenatal diagnosis for carriers of these chromosomal rearrangements. This pilot series comprises a retrospective analysis of gw-NIPS and clinical outcome data from 42 singleton pregnancies where one parent carried a balanced reciprocal translocation. Gw-NIPS was performed between August 2015 and March 2018. Inclusion criteria required at least one translocation segment to be ≥15 Mb in size. Forty samples (95%) returned an informative result; 7 pregnancies (17.5%) were high risk for an unbalanced translocation and confirmed after diagnostic testing. The remaining 33 informative samples were low risk and confirmed after diagnostic testing or normal newborn physical exam. Test sensitivity of 100% (95% confidence interval [CI]: 64.6–100%) and specificity of 100% (95% CI: 89.6–100%) were observed for this pilot series. We demonstrate that gw-NIPS is a potential option for a majority of reciprocal translocation carriers. Further confirmation of this methodology could lead to adoption of this noninvasive alternative.

‘Medically unexplained symptoms’ are positioned in mainstream healthcare discourse as an individualistic psychosocial phenomenon; this positioning occurs through application of a particular variant of the biopsychosocial model that downplays biological influences whilst ignoring critically informed social and structural influences in illness. A critical counter-narrative to mainstream healthcare narratives, one that assumes that power has a central role in constructing health-related discourse and contributing to health outcomes, is that medically unexplained symptoms serve a number of purposes for mainstream institutions, associated actors and society more broadly. These purposes include reinforcement of and justification for neoliberal socio-economic policies (notably, welfare reform), management of medical and broader societal uncertainty and seeking of moral legitimacy in the face of socio-structural injustices. This article examines socio-structural factors engendering and reinforcing current constructions of MUS that mainstream literature has hitherto ignored, discussing implications for research, clinician education and practice. A structurally competent approach to healthcare, one that acknowledges and addresses socio-structural influences in health and illness, would generate a more contextualised, holistic understanding of MUS, allowing for more equitable and truly patient-centred care whilst offering an exculpatory framework for clinical encounters.

Since the 1980s, concerts of video game music have become a widespread phenomenon attracting video game fans to classical venues across the globe. The commercial success of these concerts is exceptional and, I propose in my research, is partly due to their nostalgic appeal. This chapter examines the commercialisation of nostalgia by demonstrating nostalgia’s role in informing repertoire curation and examining how certain video games have become artifacts symbolic of childhood. Through case studies of Video Games Live, The Legend of Zelda: Symphony of the Goddesses and Pokémon: Symphonic Evolutions, this chapter demonstrates different methods used to invoke nostalgia. Two concepts of concert success will be discussed in this chapter as case studies will analyze (1) commercial success via the commodification of nostalgia and (2) the triggering of nostalgic feelings to invoke positive emotions and enhance audience enjoyment.

National research agencies are responsible for promoting excellent research that benefits all of society (1). Integrating sex, gender, and diversity analysis (SG&DA) into the design of research, where relevant, can improve research methodology, enhance excellence in science, and make research more responsive to social needs (2). National funding agencies—encouraged by scientists and social movements—have thus begun to implement policies to integrate sex, gender, and, more recently, diversity analysis into the grant proposal process, where these factors have been shown to play a role. We develop a five-part analytical framework for implementing and evaluating SG&DA policies, and use it to evaluate the quality of SG&DA policies for 22 major national funding agencies across six continents. By collecting emerging global practices for policy implementation, we seek to improve understanding of these policies and practices in efforts to enhance international collaborations and research excellence.

Background Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral annulus, frequently found in patients with high-risk arrhythmogenic mitral valve prolapse syndrome. It is unknown whether the annulus disjunction extends to the right side of the heart as tricuspid annulus disjunction (TAD), and whether it is associated with right ventricular electrical instability. Purpose We aimed to explore the presence of TAD, and if extended annulus disjunction was associated with ventricular arrhythmias. Methods We included patients with previously described MAD assessed by cardiac magnetic resonance imaging (CMR) in an ambispective cohort study. MAD and TAD was defined as ≥1 mm separation between the respective atrial wall-valve leaflet junction and the top of the ventricular myocardium. TAD was assessed in the lateral and inferior right ventricular free wall by means of the 4-chamber and right ventricular 2-chamber views, respectively. MAD circumference was assessed by a CMR study protocol with six left ventricular long axis views separated by 30 degrees. Mitral valve prolapse was defined as ≥2 mm superior displacement of any part of the mitral leaflets beyond the mitral annulus. Ventricular arrhythmias were defined as aborted cardiac arrest or non-sustained/sustained ventricular tachycardias recorded by electrocardiogram (ECG), stress ECG or Holter monitoring. Results We included 92 patients with MAD (62% female, age 47±16 years, 71% mitral valve prolapse). TAD was found in 48 (52%) patients, both in the lateral (n=40, 83%) and inferior (n=30, 63%) right ventricular free wall. Patients with TAD were older (age 51±16 years vs. 43±14 years, p=0.01), had greater MAD circumference (168±56° vs. 117±62°, p=0.001) and greater MAD distance (9.2±2.9 mm vs. 6.4±2.8 mm, p Conclusions TAD by CMR was highly prevalent in patients with MAD and was a marker of severe annulus disjunction and mitral valve prolapse. TAD was not associated with more ventricular arrhythmias. This novel marker warrants further research to explore the clinical implications of right-sided annulus disjunction. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian Research Council

Rationale: Sleep apnea (SA) is highly prevalent in patients with atrial fibrillation (AF), and both conditions are associated with adverse cardiovascular outcomes.Objectives: To determine the effec...

Sleep apnea is a serious and severely under-diagnosed sleep-related respiration disorder characterized by repeated disrupted breathing events during sleep. It is diagnosed via polysomnography which is an expensive test conducted in a sleep lab requiring sleep experts to manually score the recorded data. Since the symptoms of sleep apnea are often ambiguous, it is difficult for a physician to decide whether to prescribe polysomnography. In this study, we investigate whether helpful information can be obtained by collecting and automatically analysing sleep data using a smartphone and an inexpensive strain gauge respiration belt. We evaluate how accurately we can detect sleep apnea with wide variety of machine learning techniques with data from a clinical study with 49 overnight sleep recordings. With less than one hour of training, we can distinguish between normal and apneic minutes with an accuracy, sensitivity, and specificity of 0.7609, 0.7833, and 0.7217, respectively. These results can be achieved even if we train only on high-quality data from an entirely separate, clinically certified sensor, which has the potential to substantially reduce the cost of data collection. Data from a complete night can be analyzed in about one second on a smartphone.

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority Background Mitral valve prolapse is a common finding in patients with Marfan (MFS) and Loeys-Dietz syndromes (LDS). Mitral annulus disjunction (MAD) is an atrial displacement of the hinge point of the mitral valve that frequently coexists with mitral valve prolapse, but its clinical relevance in connective tissue disorders is unknown. Purpose To explore the association between MAD and severity of mitral valve and aortic disease in patients with MFS and LDS. Methods We included consecutive MFS patients and LDS patients fulfilling established diagnostic criteria. MAD was identified by echocardiography and defined as the distance from the ventricular myocardium to the hinge point of the posterior mitral leaflet (Figure, panel A). Aortic surgery was defined as emergency surgery for aortic dissection or prophylactic aortic surgery for aortic aneurysm. We recorded the need of mitral valve surgery including mitral valve repair or replacement. Results We included 168 patients of whom 103 (61%) had MFS and 65 (39%) had LDS. We identified MAD in 69 (41%) patients. Aortic surgery was performed in 112 (67%) patients (27 dissections and 85 prophylactic interventions). Patients with MAD were younger at the time of aortic surgery than those without MAD (p log rank = 0.02) (Figure, panel B). Patients needing aortic surgery had greater MAD distance (8 [7-10] mm vs. 7 [6-8] mm, p = 0.04). Mitral valve surgery was performed in 12 (7%) patients, more frequently in patients with MAD than in those without (16% vs. 1%, p Conclusion MAD was frequent and detected in 41% of patients with MFS and LDS. MAD was associated with a more severe disease phenotype including aortic surgery at younger age and frequent need for mitral valve surgery. Screening patients with MFS and LDS for MAD may provide prognostic information and may be relevant in planning surgical interventions. Abstract Figure

Background There is strong evidence for an association between atrial fibrillation (AF) and sleep apnea (SA). Purpose We aimed to examine the effect of treatment with continuous positive airway pressure (CPAP) on the burden of AF. Methods After a run-in period for CPAP-tolerance, we randomly assigned 108 eligible patients between 18–75 years, who had paroxysmal AF and moderate-to-severe obstructive SA (apnea-hypopnea index (AHI)≥15), to receive either CPAP treatment (n=54) plus usual care or usual care alone (n=54) for five months. An implanted loop recorder measured time in AF continuously. The primary endpoint was the difference in change of AF burden (% of time in AF) between CPAP treatment and usual care from baseline (one month prior to randomization) to the last three months of the intervention period. Secondary endpoints were changes in quality of life assessed by the Short Form-36 (SF-36), Epworth Sleepiness Scale (ESS), and the Functional Outcomes of Sleep Questionnaire (FOSQ). Results Mean (SD) age was 62.4 (7.7) years, BMI 29.4 (4.2) kg/m2, ESS 7.9 (3.2), and 76.1% were men. In the intervention group, the mean duration of adherence to CPAP therapy was 4.3 hours/night. During treatment mean AHI decreased from 27.6 events/hour at baseline to 2.3 events/hour during follow-up. Mean time in AF decreased from 5.0%-4.3% in the control group and from 5.6%-4.1% in the CPAP group, but the difference in change was not significant (p=0.52). Sub-analysis of those using CPAP> Conclusion This is the first randomized controlled trial to assess the effect of treatment of SA on the burden of AF, and did not detect a difference between those treated with CPAP compared to usual care alone. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Oslo University Hospital is the main funding Source. ResMed Science Center provided an unrestricted grant.

IntroductionBlood and imaging biomarkers show promise in prognosticating outcomes after paediatric cardiac arrest in pilot studies. We describe the methods and early recruitment challenges and solutions for an ongoing multicentre (n=14) observational trial, Personalising Outcomes following Child Cardiac Arrest to validate clinical, blood and imaging biomarkers individually and together in a clinically relevant panel.Methods and analysisChildren (n=164) between 48 hours and 17 years of age who receive chest compressions irrespective of provider, duration, or event location and are admitted to an intensive care unit are eligible. Blood samples will be taken on days 1–3 for the measurement of brain-focused biomarkers analysed to predict the outcome. Clinically indicated and timed brain MRI and spectroscopy biomarkers will be analysed to predict the outcome. The primary outcome for the trial is survival with favourable (Vineland Adaptive Behavioural Scale score >70) outcome at 1 year. Secondary outcomes include mortality and pre-event and postdischarge measures of emotional, cognitive, physical and family functioning and health-related quality of life. Early enrollment targets were not met due to prolonged regulatory and subcontract processes. Multiple, simultaneous interventions including modification to inclusion criteria, additional sites and site visits were implemented with successful improvement in recruitment. Study procedures including outcomes and biomarker analysis are ongoing.Ethics and disseminationTwelve of 14 sites will use the centralised Institutional Review Board (IRB) at the University of Pittsburgh (PRO14030712). Two sites will use individual IRBs: Children’s Healthcare of Atlanta Institutional Review Board and Children’s Hospital of Wisconsin IRB. Parents and/or guardians are consented and children assented (when possible) by the site Primary investigator (PI) or research coordinator for enrollment. Study findings will be disseminated through scientific conferences, peer-reviewed journal publications, public study website materials and invited lectures.Trial registration numberNCT02769026.

There is strong evidence for an association between atrial fibrillation (AF) and sleep apnea (SA). We aimed to examine the effect of treatment with continuous positive airway pressure (CPAP) on the burden of AF. We randomly assigned 108 patients between 18-75 years, who had paroxysmal AF and moderate-to-severe obstructive SA (apnea-hypopnea index (AHI)≥15) to receive either CPAP treatment (n=54) plus usual care or usual care alone (n=54) for five months. An implanted loop recorder measured time in AF continuously. The primary endpoint was the difference in change of AF burden (% of time in AF) between CPAP treatment and usual care from baseline (one month pre randomization) to the last three months of the intervention period. Secondary endpoints were changes in quality of life assessed by the Short Form-36 (SF-36), Epworth Sleepiness Scale (ESS) and the Functional Outcomes of Sleep Questionnaire (FOSQ) Mean (SD) age was 62.4 (7.7) years, BMI 29.4 (4.2) kg/m², ESS 7.9 (3.2), and 76.1% were men. In the intervention group, the mean duration of adherence to CPAP therapy was 4.3 hours/night. During treatment mean AHI decreased from 27.6 events/hour at baseline to 2.3 events/hour during follow-up. Mean time in AF decreased from 5.0%-4.3% in the control group and from 5.6%-4.1% in the CPAP group, but the difference in change was not significant (p=0.52). Subanalysis of those using CPAP> This is the first randomized controlled trial to assess the effect of treatment of SA on the burden of AF, and did not detect a difference between those treated with CPAP compared to usual care alone.

PurposeTo describe our experience of offering simultaneous genetic carrier screening for cystic fibrosis (CF), fragile X syndrome (FXS), and spinal muscular atrophy (SMA).MethodsCarrier screening is offered through general practice, obstetrics, fertility, and genetics settings before or in early pregnancy. Carriers are offered genetic counseling with prenatal/preimplantation genetic diagnosis available to those at increased risk.ResultsScreening of 12,000 individuals revealed 610 carriers (5.08%; 1 in 20): 342 CF, 35 FXS, 241 SMA (8 carriers of 2 conditions), approximately 88% of whom had no family history. At least 94% of CF and SMA carriers' partners were tested. Fifty couples (0.42%; 1 in 240) were at increased risk of having a child with one of the conditions (14 CF, 35 FXS, and 1 SMA) with 32 pregnant at the time of testing. Of these, 26 opted for prenatal diagnosis revealing 7 pregnancies affected (4 CF, 2 FXS, 1 SMA).ConclusionThe combined affected pregnancy rate is comparable to the population risk for Down syndrome, emphasizing the need to routinely offer carrier screening. The availability of appropriate genetic counseling support and a collaborative approach between laboratory teams, genetics services, health professionals offering screening, and support organizations is essential.

Balanced reciprocal translocation carriers are at increased risk of producing gametes with unbalanced forms of the translocation leading to miscarriage, fetal anomalies, and birth defects. We sought to determine if genome-wide cell-free DNA based noninvasive prenatal screening (gw-NIPS) could provide an alternative to prenatal diagnosis for carriers of these chromosomal rearrangements.This pilot series comprises a retrospective analysis of gw-NIPS and clinical outcome data from 42 singleton pregnancies where one parent carried a balanced reciprocal translocation. Gw-NIPS was performed between August 2015 and March 2018. Inclusion criteria required at least one translocation segment to be ≥15 Mb in size.Forty samples (95%) returned an informative result; 7 pregnancies (17.5%) were high risk for an unbalanced translocation and confirmed after diagnostic testing. The remaining 33 informative samples were low risk and confirmed after diagnostic testing or normal newborn physical exam. Test sensitivity of 100% (95% confidence interval [CI]: 64.6-100%) and specificity of 100% (95% CI: 89.6-100%) were observed for this pilot series.We demonstrate that gw-NIPS is a potential option for a majority of reciprocal translocation carriers. Further confirmation of this methodology could lead to adoption of this noninvasive alternative.

ObjectivesThe issue of polypharmacy and medication use in people with life limiting illness raises important questions from a clinical and ethical viewpoint. The objectives of our study were to (1) explore medication use among people with life limiting illness receiving hospice care; (2) apply consensus criteria to assess medication appropriateness; and (3) determine the overall pill burden in this patient population.MethodsSix hospices in the North East of England were included. All deceased adult patients who received hospice care in 2018 were eligible for study inclusion. Descriptive statistics were used to report medication details; while medication appropriateness was assessed according to consensus criteria developed by Morin and colleagues.ResultsSix hundred and ninety patients were included in the study. Patients were using a mean number of 8.8 medications per day, while polypharmacy was evident in 80% of patients. In terms of potentially questionable medication, patients were prescribed a mean number of 1.3 per day. Common potentially questionable medications included vitamin and mineral supplements, antihypertensives, antiplatelets, lipid regulating agents and anticoagulants. The pill burden in this population was also high with, on average, people using 13.7 oral doses per day.ConclusionsPolypharmacy is common in patients accessing hospice care, as is the use of potentially questionable medication. The pill burden in this patient population is also high, which may be an additional treatment burden to patients. Holistic deprescribing approaches for this population should be developed and implemented.

Background: The association between sleep apnea (SA) and atrial fibrillation (AF) is strong. SA is probably underdiagnosed in AF patients. Polysomnography (PSG) is time consuming and costly and a valid screening tool is warranted. Aims and Objectives: The aim was to determine if the Berlin Questionnaire (BQ) and the STOP-Bang Questionnaire (SBQ) can be used as a screening tool in patients with paroxysmal atrial fibrillation (PAF). Methods: We prospectively studied 565 PAF patients. Risk for sleep apnea was assessed with the BQ and the SBQ. SA was defined as an apnea-hypopnea index (AHI) ≥15/h obtained by polygraphy (PG) two nights at home. Sleep studies were analyzed by an experienced specialist, using standard American Academy of Sleep Medicine definitions. A BQ high risk subject was defined as ≥2 of 3 risk factors: (I) snoring; (II) daytime somnolence; and (III) hypertension or a body mass index (BMI) > 30 kg/m². A SBQ high risk subject was defined as ≥5 affirmative answers to the 8 STOP-Bang items. Results: Mean age was 60 (9) years and mean BMI 29 (4) kg/m². 238 (42%) had an AHI ≥ 15/h. According to SBQ low, intermediate and high risk of SA was 7%, 14% and 21% respectively. The SBQ score ≥3 was 84% sensitive and 45 % specific for diagnosis of SA. For those with low risk and high risk according to the BQ score 19% and 23% had SA, respectively. The BQ performed with 56% sensitivity and 70% specificity. Conclusions: Of two commonly used questionnaires to screen for SA, neither the SBQ nor the BQ questionnaire discriminated well between those with or without SA in patients with PAF. Until better screening tools are available PG or PSG needs to be used to detect SA in these patients.

Background: Recent studies have suggested a strong association between sleep apnea (SA) and atrial fibrillation (AF). Aims and Objectives: In this study we aimed to examine clinical predictors to identify SA and the prevalence and type of SA in patients with paroxysmal AF. Methods: We prospectively studied 578 patients with paroxysmal AF. SA was diagnosed using portable polygraphy two nights at home. Sleep studies were analyzed by an experienced specialist, using standard American Academy of Sleep Medicine definitions. The degree of subjective daytime sleepiness was assessed by Epworth Sleepiness Scale (ESS). Body composition data were collected using a body composition analyzer (Tanita BC-545N). We calculated differences in variables between SA categories by Chi-Square Test or ANOVA as appropriate. Results: 158 women (27 %) and 420 men (73%) were enrolled. Mean age (SD) was 60 (10) years and mean BMI 29 (4) kg/m². 477 (83%) of the patients had an apnea-hypopnea index (AHI) ≥ 5/h, while moderate/severe SA (AHI ≥ 15/h) was diagnosed in 243 patients (42%). The type of SA was predominantly obstructive, with mean AHI 15.3/h (12) (range 0.4/h-85.8/h). Mean central apnea index was 0.8/h (2). AHI increased with age, BMI, weight, neck-and waist circumference, body fat, visceral fat and metabolic age. Mean ESS score was 7 (4). There was no association between ESS and AHI/h, r=0.08. Conclusions: In our AF population the prevalence of SA (AHI ≥ 5/h) was 83 %, which is several times higher than in the general population (16%). The high prevalence of SA detected in this study may indicate that SA is under-recognized in patients with AF. We found a positive correlation between body composition and SA severity.

Background Repeat chlamydia infections are common, and the risk of receiving complications increases with the number of lifetime infections. However, retesting rates in the UK remain low and interventions to increase retesting have had variable effects. In order to change behaviour (e.g., to increase retesting), behavioural-science theoretical models may help identify influential factors. One such model, the COM-B Model proposes behaviour results from an interaction between capability, opportunity and motivation. The aim of this study was to identify theoretically-based demographic and psychosocial factors associated with retesting behaviour and intentions to retest amongst those previously diagnosed with chlamydia. Methods An online questionnaire was developed, based on a comprehensive literature review and expert and lay consultation. Participants were 263 young people (16–24 years) in the UK who had been diagnosed with chlamydia (via healthcare settings or online platforms). In addition to demographic questions, each measure was representative of COM-B components: susceptibility and severity, fear, stigma, shame, knowledge, social support, social norms, perceived advantages/disadvantages of retesting. Results 35% had not retested, the most common reason for which was unawareness of the need to retest (31%). In those who had not retested, moral norms, injunctive norms, and STI knowledge significantly predicted intentions to retest (F[1,53]=6.20,p=0.016,R2 =0.45,AdjR2=0.42). Retesters were slightly older and more likely to have had other STIs. The most common location of retest was a sexual health clinic (57%), followed by general practice (14%) and online services (11%). Multivariable regression demonstrated that social norms (injunctive, descriptive, and moral) significantly predicted having retested (F[1,171]=7.44, p=0.007,R2 =0.12,AdjR2=0.10]. Conclusion This research has identified potential targets for public health campaigns aimed at eliminating STIs. Specifically, future interventions should focus on social (e.g., social approval one expects from others for engaging in a responsible sexual health action) and psychological (awareness and education) to increase retesting rates. Disclosure No significant relationships.

Children with conduct problems benefit less from empirically supported interventions for disruptive behaviors when callous-unemotional (CU) traits (i.e., lack of empathy/guilt) are also present. Traditional “gold-standard” interventions for disruptive behavior disorders that focus primarily on improving parenting skills fail to address the core deficits in emotional processing and empathic responding unique to children with co-occurring conduct problems and CU traits (CP + CU). This case study presents a follow-up of the treatment of a young boy with severe disruptive behavior and pronounced CU traits using a novel, brief adjunctive treatment called Coaching and Rewarding Emotional Skills (CARES). Findings (a) indicate short-term improvements in empathic responding and emotion recognition with CARES and (b) provide preliminary support for supplementing parent training with a brief adjunctive intervention to improve socio-emotional behavior and CU traits. Novel targeted interventions for children with CP + CU are critically needed given their poor prognosis and long-term impairment.

The 2 dimensions of psychopathy as operationalized by various measurement tools show differential associations with psychopathology; however, evidence suggests that the statistical interaction of Factor 1 (F1) and Factor 2 (F2) may be important in understanding associations with psychopathology. Findings regarding the interactive effects of F1 and F2 are mixed, as both potentiating and protective effects have emerged. Moreover, approaches to measuring F1 (e.g., clinical interview vs. self-report) are based on different conceptualizations of F1, which may influence the interactive effects. The current study aims to (a) elucidate the influence of F1 and F2 on psychopathology by using both variable-centered and person-centered approaches and (b) determine whether the measurement of F1 influences the interactive effects of F1 and F2 by comparing the strength of interactive effects across F1 measures in a sample of over 1,500 offenders. Across analytic methods, there were very few cases in which F1 statistically influenced the association between F2 and psychopathology, such that F1 failed to evidence either potentiating or protective effects on F2. Furthermore, the conceptualization of F1 across psychopathy measures did not impact the interactive effects of F1 and F2. These findings suggest that F2 is probably driving the relations between psychopathy and other forms of psychopathology and that F1 may play less of a role in interacting with F2 than previously believed.

This chapter examines the progress of women's participation and representation in the House of Commons. It first considers women's descriptive representation in the House of Commons over the last century, with emphasis on the differences in the proportion of women Members of Parliament (MPs) elected by the main political parties. It explains improvements in the numbers of women MPs in the last decade or so, together with the party asymmetry, by reference to the supply and demand model of political recruitment. It then reviews arguments for women's equal participation in politics, taking into account how women's descriptive representation intersects with symbolic and substantive representation. It also discusses resistance to the claim that women's representation matters and concludes with an analysis of the masculinized nature of the political institution that women MPs inhabit, along with the recommendations made in the 2016 The Good Parliament report.

Objective Despite the high prevalence of substance use disorders, mental disorders, and co-occurring disorders among persons in the justice system, there is a fairly low rate of treatment utilization among this population. This study explored rates of lifetime behavioral health treatment utilization and factors associated with involvement in treatment. Methods The study examined data from the Arrestee Drug Abuse Monitoring II program from 2007 to 2010, including over 18,000 arrestees in 10 U.S. metropolitan jails. Logistic regression and χ² analyses were used to explore the relationship between self-reported lifetime treatment history and sociodemographic characteristics, self-reported substance use, and severity of substance use. Results Over half of arrestees reported no history of behavioral health treatment (62%), and Caucasians were significantly more likely to have received treatment than African Americans and Hispanics. Rates of treatment for substance use disorders or for both substance use and mental disorders were lowest among arrestees reporting marijuana and alcohol use and highest for heroin users. Methamphetamine users were the most likely to have received prior mental health treatment. Severity of alcohol and drug use was the highest among arrestees who had received both substance abuse and mental health treatment. Conclusions and implications for practice Considering the high rates of mental and substance use disorders in this population, the overall lack of behavioral health service utilization among offenders is concerning and points to the need to engage offenders in mental health and substance abuse treatment and to expand these services in jails, prisons, diversionary programs, and community corrections settings. (PsycINFO Database Record

The study examined data from the Arrestee Drug Abuse Monitoring-II (ADAM-II) program from 2007 until 2010 at 10 U.S. metropolitan jails to determine factors influencing the accuracy of self-reported drug use. The overall kappa coefficient for self-report data and urinalysis results of any type of drug use in the past 72 hr was.52, indicating a moderate level of agreement. Greater accuracy in self-reported drug use was found among arrestees who tested positive for methamphetamine and marijuana, although these results differed by age and race/ethnicity. African Americans provided less accurate self-reports of drug use than Caucasians, and younger arrestees less accurately self-reported all types of drug use except for marijuana. Persons with no prior arrests had higher accuracy of self-reported drug use than those with a history of frequent arrests, and prior involvement in substance abuse treatment was associated with more accurate self-reporting of drug use. FINDINGS indicate moderate accuracy of self-reported drug use among new arrestees, with the accuracy influenced by demographic factors, arrest history, and substance abuse treatment history. Keywords: Juvenile justice Language: en

Current research has established a number of robust predictors of child disruptive behavior disorder (DBD) symptoms. These include maladaptive, inconsistent, harsh, punitive, or abusive parenting; marital conflict among parents; divorce; and parental antisocial behavior. Across both clinical and community samples, maladaptive parental disciplinary practices are linked with offspring attention-deficit hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD) , and conduct disorder (CD) symptoms (Loeber & Stouthamer-Loeber, 1986; Burt et al. 2003; Caspi et al. 2004; Stormshak et al. 2000; Stanger et al. 2004). Similarly, divorce and marital discord are significantly related to DBD symptoms (Gartstein & Fagot, 2003; Burt et al. 2008). Finally, one of the strongest predictors of child conduct problems is parental antisocial behavior (Herndon & Iacono, 2005), as it is consistently associated with offspring DBD symptoms, delinquency, and criminal acts. Arguably, these studies put forth familial factors as environmental risk factors contributing directly to child DBD symptoms. Indeed, a recent meta-analysis of twin studies reported that shared environmental factors (i.e., factors common to both members of a sibling pair that make them similar) accounted for 10%–15% of the variance in child DBD symptoms and diagnoses (Burt, 2009). Other studies indicate familial risk factors are associated with child DBD symptoms in large part through shared environmental mechanisms (McGue et al. 1996; Pike et al. 1996; Burt et al. 2003; Burt et al. 2007;). However, additional research on the link between familial risk factors and child DBD symptoms suggests alternative explanations which implicate genetic influences. One key finding largely supporting this is that parental antisociality is highly heritable. In a review of studies on the etiology of child antisociality, Rhee and Waldman (2002) found genes influenced 32% of the variance in child antisociality, and shared environmental factors influenced 16%. Previous studies (Bornovalova. 2010) indicate parental externalizing psychopathology (including adult antisociality) influences child DBD symptoms through transmitting a common genetic vulnerability. Likewise, multiple studies report genetic influences on marital relationships (Reiss et al. 2000; Spotts et al. 2004; Spotts et al. 2006), divorce (McGue & Lykken, 1992), and maladaptive parenting (Jaffee & Price, 2008; see Kendler & Baker, 2007 for a review). Collectively, this research suggests patterns of influence generally attributed to the familial environment are in part genetically mediated. Putative environmental factors may be indirectly related to offspring DBD symptoms through the mechanism of passive gene-environment correlation (rGE). Passive rGE occurs when parents provide both the genes and environment that lead to a certain child outcome. As applied to the current topic, a heritable propensity toward impulsive and disinhibitory behavior may increase likelihood of exhibiting high antisocial traits, especially while being reared in an environment characterized by marital conflict, divorce, and maladaptive parenting. The combination of genetic and environmental risk in turn increases likely manifestation of child DBD symptoms in the offspring (Bornovalova, 2010; Silberg et al. 2012). Unfortunately, neither studies of biological families nor typical twin designs are able to disentangle environmental sources of influence from passive rGE because parents provide both genes and environment for their biological children. And, in classic twin designs, passive rGE can mimic shared environmental influences when the origins are, in fact, a function of common parent– child genes. An elegant method of disentangling environmental influences from passive rGE involves comparing the effects of putative environmental variables in genetically unrelated families (adoptive families) and genetically related families (biological families). The logic of this design is as follows: In families where the biological parents are rearing their own offspring, parents provide both the child’s environment and his/her genes. Thus, any association between parenting and child DBD symptoms could be due to genetically mediated influences, purely environmental influences, or any combination of the two. In contrast, in an adoptive family, the child’s adoptive parents provide the environment, but the child’s birth parents provide his/her genetic makeup and typically do not provide environmental influences after the child was adopted. As such, the possibility of passive rGE is eliminated (provided children are not selectively placed into adoptive homes). If the magnitude of association between familial factors and child DBD symptoms is significantly greater in biological families than in adoptive families, then some degree of passive rGE is indicated because the association between family environment and biological offspring outcomes depends on both genetic and shared environmental factors. Conversely, if the magnitude of the familial factors-child DBD symptoms association is comparable in biological and adoptive families, then passive rGE effects are ruled out and environmental risk processes are implicated (Plomin, 1994). Six previous studies (Dunn et al. 1985; Dunn & Plomin, 1986; Dunn et al. 1986; Rende et al. 1992; Braungartrieker et al. 1995; O'Connor et al. 2000) used this design to examine contribution of passive rGE in the association between familial risk factors and DBD symptoms. Findings generally indicated, with the exception of divorce (which consistently shows solely a direct environmental effect), a mix of direct environmental effects and passive rGE effects. Using a very different method (the Extended Children of Twins Design, a design incorporating children of twins and their cousins capitalizing on a large range of genetic relatedness in immediate and extended family), at least four other studies (Neiderhiser et al. 2004; Harden et al. 2007; Neiderhiser et al. 2007; Narusyte et al. 2011; Silberg et al. 2012) found similar effects. Collectively, these studies suggest both passive rGE and direct environmental effects account for the relationship between family conflict, parenting behavior, and parental antisociality and child DBD symptoms. Although these studies contribute importantly to understanding the relative influence of environmental effects and rGE, each examined one or two selected contextual risk factors making it difficult to evaluate the relative contribution of each. Moreover, previous work suggests the importance of examining maternal and paternal parenting factors separately (Rothbaum & Weisz, 1994; Denham et al. 2000; Johnson et al. 2001) but only a few studies (Neiderhiser et al. 2004; Neiderhiser et al. 2007) have investigated possible differences between fathering and mothering in the interplay between genetic and environmental factors. This last point is quite important, as the effects of maternal versus paternal parenting effects may differ in (a) strength of effect, and (b) underlying mechanism of transmission (Rothbaum & Weisz, 1994; Denham et al. 2000; Johnson et al. 2001; Neiderhiser et al. 2004; Neiderhiser et al. 2007). Additionally, among these studies there is large variability in offspring age (ranging from toddlers to adolescents). It is important to extend these studies by examining the effects of multiple familial risk factors on child DBD symptoms late enough in development to allow manifestation of such symptoms. Finally, it is especially worthwhile to attempt to replicate and extend findings from multiple studies using widely different methods (e.g., adoptive designs; Extended Children of Twins Designs), since confidence in the veracity of an effect increases if the same results are found using multiple methodological approaches.

Phylogenetic relationships among members of the New World searobin genera Bellator and Prionotus (Family Triglidae, Subfamily Prionotinae) and among other searobins in the families Triglidae and Peristediidae were investigated using both mitochondrial and nuclear DNA sequences. Phylogenetic hypotheses derived from maximum likelihood and Bayesian methodologies supported a monophyletic Prionotinae that included four well resolved clades of uncertain relationship; three contained species in the genus Prionotus and one contained species in the genus Bellator. Bellator was always recovered within the genus Prionotus, a result supported by post hoc model testing. Two nominal species of Prionotus (P. alatus and P. paralatus) were not recovered as exclusive lineages, suggesting the two may comprise a single species. Phylogenetic hypotheses also supported a monophyletic Triglidae but only if armored searobins (Family Peristediidae) were included. A robust morphological assessment is needed to further characterize relationships and suggest classification of clades within Prionotinae; for the time being we recommend that Bellator be considered a synonym of Prionotus. Relationships between armored searobins (Family Peristediidae) and searobins (Family Triglidae) and relationships within Triglidae also warrant further study.

Identifying the point at which individuals become at risk for academic failure (grade point average [GPA] < 2.0) involves an understanding of which and how many factors contribute to poor outcomes. School-related factors appear to be among the many factors that significantly impact academic success or failure. This study focused on 12 school-related factors. Using a thorough 5-step process, we identified which unique risk factors place one at risk for academic failure. Academic engagement, academic expectations, academic self-efficacy, homework completion, school relevance, school safety, teacher relationships (positive relationship), grade retention, school mobility, and school misbehaviors (negative relationship) were uniquely related to GPA even after controlling for all relevant covariates. Next, a receiver operating characteristic curve was used to determine a cutoff point for determining how many risk factors predict academic failure (GPA < 2.0). Results yielded a cutoff point of 2 risk factors for predicting academic failure, which provides a way for early identification of individuals who are at risk. Further implications of these findings are discussed.

The enactment of the Adam Walsh Child Protection and Safety Act in 2006 is an extension of current protective legislation aimed at establishing stricter sanctions for community-released sexual offenders. What largely separates the Adam Walsh Act from previous registration and notification laws is the crossing of traditional jurisdictional boundaries between adult and juvenile courts at the federal level. This article addresses several key concerns relating to the application of these federal standards to adolescent offenders. In addition to a review of the extant literature, we present findings from an exploratory evaluation that examines the ability of the Adam Walsh Act’s classification system to predict future offending among a sample of 112 adjudicated juvenile sex offenders over a 2-year outcome period. Results indicate that offenders who met criteria for registration did not reoffend (sexually or nonsexually) at a significantly higher rate than those who did not meet registration criteria. Implications regarding appropriate risk assessment and management of youth sexual offenders are discussed.

The legal files of 144 juveniles charged as adults in one Pennsylvania county were reviewed to investigate whether trauma-related information was included in evaluations of amenability to treatment and how that information related to legal decisions to keep youth in criminal court or decertify them to the juvenile system. Potentially traumatic experiences (PTEs) were noted in more than 71% of evaluations. Youth with any PTE documented were more likely to remain in criminal court, have more prior arrests, report regular marijuana use, and have mental health diagnoses associated with offending behaviors. Youth with direct (versus witnessed) exposure to PTEs were more likely to have been placed out of home and to be diagnosed with other mental health disorders. However, only 6% of the evaluations specifically recommended treatment for trauma-related issues, and documentation of PTEs was not associated with the ultimate legal decision except in cases involving severe injury.

Several different types of treatment-based court programs have been developed in the United States, including drug courts and mental health courts. These programs provide opportunities for diversion from jail or prison and involvement in a coordinated set of treatment and supervision services that focus on the unique needs of justice-involved persons who have behavioral health disorders. Approximately 400 adult and juvenile mental health courts have been implemented in 46 states. Key program elements include targeting persons with severe mental illness, rapid engagement in comprehensive mental health, substance abuse, and other community services; protection of confidentiality, and use of a multidisciplinary team to deliver services and to monitor participant progress and program success. Mental health court evaluations indicate reductions in criminal recidivism and enhanced engagement in intensive mental behavioral health services among program participants, in contrast to similar groups of individuals who do not receive these services. Keywords: diversion programs; specialty courts; treatment-based courts

Uncertainty is a major source of psychological strain during organizational change. This study tested a model of change-related communication, uncertainty, and control and their relationship with psychological strain, job satisfaction, and turnover intentions. Self-report data were obtained from staff at a psychiatric hospital undergoing restructuring. Results indicated that uncertainty had a direct and an indirect (via feelings of lack of control) relationship with psychological strain. Partialling out common method variance led to a complete mediation of this relationship by control. Other predictions about the relationship of these variables with psychological strain, job satisfaction, and turnover intentions were supported. Implications for future research and practice of change communication are discussed.

Water conservation policy is a natural laboratory for addressing general issues of relevance to policy analysis and public administration, particularly the relative effectiveness of policies in changing human behavior. Using multivariate regression analysis of a dataset comprised of more than 200,000 monthly observations of more than 19,000 household accounts over six years, this paper makes three main contributions. First, it contributes to the substantive area of water conservation policy by analyzing what works. Second, it contributes to our understanding of generic policy instruments. Third, it raises an important issue regarding standard assumptions about selection bias. The results support earlier work warning that offsetting behavior can negate engineering solutions to policy problems, but further indicate that adding communication to engineering solutions can create cooperation that overcomes offsetting behavior. They also provide evidence that appropriate regulation can be effective, and that pricing can be effective even when price elasticities of demand are low.

The plasmodesmata and phloem form a symplasmic network that mediates direct cell–cell communication and transport throughout a plant. Selected endogenous RNAs, viral RNAs, and viroids traffic between specific cells or organs via this network. Whether an RNA itself has structural motifs to potentiate trafficking is not well understood. We have used mutational analysis to identify a motif that the noncoding Potato spindle tuber viroid RNA evolved to potentiate its efficient trafficking from the bundle sheath into mesophyll that is vital to establishing systemic infection in tobacco (Nicotiana tabacum). Surprisingly, this motif is not necessary for trafficking in the reverse direction (i.e., from the mesophyll to bundle sheath). It is not required for trafficking between other cell types either. We also found that the requirement for this motif to mediate bundle sheath-to-mesophyll trafficking is dependent on leaf developmental stages. Our results provide genetic evidence that (1) RNA structural motifs can play a direct role in mediating trafficking across a cellular boundary in a defined direction, (2) the bundle sheath–mesophyll boundary serves as a novel regulatory point for RNA trafficking between the phloem and nonvascular tissues, and (3) the symplasmic network remodels its capacity to traffic RNAs during plant development. These findings may help further studies to elucidate the interactions between RNA motifs and cellular factors that potentiate directional trafficking across specific cellular boundaries.

Forensic assessment is a specific type of evaluation used to gather information to assist legal decision makers. It differs from standard clinical assessment in several ways, including its purpose, the evaluator's role/relationship with the examinee, the limits of confidentiality and voluntariness of the evaluation, and the type of testimony. Given the nature and context of forensic assessment, careful attention must be paid to the examinee's response style and the potential for malingering. Forensic assessment should be comprehensive by including multiple sources of information and approaches to collecting data. When appropriate, the information obtained through this evaluation should be presented clearly with explicit mention of the procedures used and the basis for each conclusion. Keywords: forensic psychology; practice in clinical psychology; assessment

Child maltreatment cases can be fairly complex because of the mixture of interests among the different parties involved and the difficult decisions often made in these contexts, such as termination of parental rights. Psychologists can play an important role in the handling of maltreatment cases in dependency court by performing evaluations to assist legal decision makers in making informed decisions about the child's best interests to ensure his or her protection. The dependency system seeks to protect children from harmful situations associated with inadequate parenting and provide placement and necessary services to ensure the child's wellbeing. Keywords: child dependency; child maltreatment; child protection; children; family law; trauma

Third-party information (TPI) is defined as a type of collateral source that is not obtained directly from the individual being evaluated. It serves an essential role in forensic mental health assessment for three primary reasons: greater need for accuracy, issues with response style, and the greater scrutiny that the evaluator's conclusions may receive. TPI may be obtained through interviews with personal and professional collateral informants or through reviews of various forms of written documentation. TPI may be used to help detect response styles and malingering, making it vital to evaluation of the validity of the examinees self-report and to ensure that an accurate opinion has been formed and communicated to the courts. Keywords: assessment; criminal justice; decision making; evaluation; forensic

BackgroundPrevious studies have reported strong genetic and environmental overlap between antisocial-externalizing (factor 2; F2) features of psychopathy and borderline personality disorder (BPD) tendencies. However, this line of research has yet to examine etiological associations of affective-interpersonal (factor 1, F1) features of psychopathy with BPD tendencies.MethodThe current study investigated differential phenotypic and genetic overlap of psychopathy factors 1 and 2 with BPD tendencies in a sample of over 250 male and female community-recruited adult twin pairs.ResultsConsistent with previous research, biometric analyses revealed strong genetic and non-shared environmental correlations of F2 with BPD tendencies, suggesting that common genetic and non-shared environmental factors contribute to both phenotypes. In contrast, negative genetic and non-shared environmental correlations were observed between F1 and BPD tendencies, indicating that the genetic factors underlying F1 serve as protective factors against BPD. No gender differences emerged in the analyses.ConclusionsThese findings provide further insight into associations of psychopathic features – F1 as well as F2 – and BPD tendencies. Implications for treatment and intervention are discussed, along with how psychopathic traits may differentially influence the manifestation of BPD tendencies.

With increased public awareness of the risks of blood transfusion and the decreased availability of blood products, the decision to transfuse a patient should be considered carefully. Most patients require a blood transfusion when haemoglobin levels fall below 8 g=dl or when there is greater than 30% loss of blood volume. However, the main indication for transfusing a patient is to increase their oxygen-carrying capacity and through invasive monitoring provide evidence of inadequate tissue oxygenation. Blood transfusions should be based on the patient’s risks of developing complications of inadequate oxygenation rather than on a single haemoglobin ‘trigger’.