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Background: The burden of musculoskeletal conditions continues to grow in low‐ and middle‐income countries. Among thousands of surgical outreach trips each year, few organizations electronically track patient data to inform real‐time care decisions and assess trip impact. We report the implementation of an electronic health record (EHR) system utilized at point of care during an orthopedic surgical outreach trip. Methods: In March 2023, we implemented an EHR on an orthopedic outreach trip to guide real‐time care decisions. We utilized an effectiveness‐implementation hybrid type 3 design to evaluate implementation success. Success was measured using outcomes adopted by the World Health Organization, including acceptability, appropriateness, feasibility, adoption, fidelity, and sustainability. Clinical outcome measures included adherence to essential quality measures and follow‐up numerical rating system (NRS) pain scores. Results: During the 5‐day outreach trip, 76 patients were evaluated, 25 of which underwent surgery beforehand. The EHR implementation was successful as defined by: mean questionnaire ratings of acceptability (4.26), appropriateness (4.12), feasibility (4.19), and adoption (4.33) at least 4.00, WHO behaviorally anchored rating scale ratings of fidelity (6.8) at least 5.00, and sustainability (80%) at least 60% follow‐up at 6 months. All clinical quality measures were reported in greater than 80% of cases with all measures reported in 92% of cases. NRS pain scores improved by an average of 2.4 points. Conclusions: We demonstrate successful implementation of an EHR for real‐time clinical use on a surgical outreach trip. Benefits of EHR utilization on surgical outreach trips may include improved documentation, minimization of medical errors, and ultimately improved quality of care. [ABSTRACT FROM AUTHOR]

ObjectivesTo examine relationships between cognitive expectancies about sleep and hypnotics and use of medications commonly used for insomnia (hypnotics).MethodsWe analyzed baseline data from older veterans who met diagnostic criteria for insomnia and were enrolled in a trial comparing CBTI delivered by a supervised, sleep educator to an attention control condition (N = 159; 97% male, mean age 72 years). We classified individuals as hypnotic users (N = 23) vs. non-users (N = 135) based upon medication diaries. Associations between hypnotic status and Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS) total score (0-10, higher = worse) and two DBAS medication item scores (Item 1: "…better off taking a sleeping pill rather than having a poor night's sleep;" Item 2: "Medication… probably the only solution to sleeplessness"; 0-10, higher = worse) were examined in logistic regression models.ResultsHigher scores on the DBAS medication items (both odds ratios = 1.3; p-values < .001) were significantly associated with hypnotic use. DBAS-16 total score was not associated with hypnotic use.ConclusionCognitive expectancy (dysfunctional beliefs) about hypnotics was associated with hypnotic use in older adults with chronic insomnia disorder.Clinical implicationsStrategies that specifically target dysfunctional beliefs about hypnotics are needed and may impact hypnotic use in older adults.

We examined whether baseline self-reported physical activity is associated with the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in older veterans. Community-dwelling veterans aged 60 years and older with insomnia received CBT-I in a randomized controlled trial. Participants who received active treatment were divided into low and high physical activity based on self-report. Sleep outcomes were measured by sleep diary, questionnaire and wrist actigraphy; collected at baseline, post-treatment, 6-month and 12-month follow-up. Mixed-effects models compared differences between physical activity groups in change in sleep outcome from baseline to each follow-up, and equivalence tests examined if physical activity groups were clinically equal. There were no significant differences in sleep outcomes between physical activity groups. Equivalence tests suggested possible equality in physical activity groups for five of seven sleep outcomes. Efficacy of CBT-I in older veterans was not associated with self-reported physical activity at baseline. Older adults with insomnia who report low levels of physical activity can benefit from CBT-I.

Study objectiveTo test the effectiveness of a 4-week behavioral Sleep Intervention Program (SIP: sleep compression, modified stimulus control, and sleep hygiene) compared to a 4-week information-only control (IC) among older adults attending a VA Adult Day Health Care (ADHC) program in a double-blind, randomized, clinical trial.MethodsForty-two individuals (mean age: 77 years, 93% male) enrolled in a VA ADHC program were randomized to receive SIP or IC. All completed in-person sleep and health assessments at baseline, post-treatment and 4-months follow-up that included 3 days/nights of wrist actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI). Mixed repeated measures analysis was used to compare sleep outcomes at post-treatment and 4-months follow-up, with baseline values as covariates.ResultsSIP participants (n = 21) showed significant improvement on actigraphy sleep efficiency (p = .007), number of nighttime awakenings (p = .016), and minutes awake at night (p = .001) at post-treatment, compared to IC participants (n = 21). Benefits were slightly attenuated but remained significant at 4-month follow-up (all p's < .05). There were no differences in total sleep time between groups. There was significant improvement on PSQI factor 3 (daily disturbances) at 4-month follow-up (p = .016), but no differences were observed between SIP and IC on other PSQI components or ISI scores at post-treatment or 4-month follow-up.ConclusionsA short behavioral sleep intervention may have important benefits in improving objectively measured sleep in older adults participating in ADHC. Future studies are needed to study implementation of this intervention into routine clinical care within ADHC.

ObjectivesTo test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians.DesignRandomized controlled trial.SettingDepartment of Veterans Affairs healthcare system.ParticipantsCommunity-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159).InterventionNonclinician "sleep coaches" delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education.MeasurementsPrimary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)).ResultsIntervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (-23.4, -15.8, and -17.3 minutes, respectively), TWT-D (-68.4, -37.0, and -30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (-3.4, -2.4, and -2.1 in total score, respectively), and ISI (-4.5, -3.9, and -2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2.ConclusionManual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.

Face Morphing Attacks pose a threat to the security of identity documents, especially with respect to a subsequent access control process, because they allow both involved individuals to use the same document. Several algorithms are currently being developed to detect Morphing Attacks, often requiring large data sets of morphed face images for training. In the present study, face embeddings are used for two different purposes: first, to pre-select images for the subsequent large-scale generation of Morphing Attacks, and second, to detect potential Morphing Attacks. Previous studies have demonstrated the power of embeddings in both use cases. However, we aim to build on these studies by adding the more powerful MagFace model to both use cases, and by performing comprehensive analyses of the role of embeddings in pre-selection and attack detection in terms of the vulnerability of face recognition systems and attack detection algorithms. In particular, we use recent developments to assess the attack potential, but also investigate the influence of morphing algorithms. For the first objective, an algorithm is developed that pairs individuals based on the similarity of their face embeddings. Different state-of-the-art face recognition systems are used to extract embeddings in order to pre-select the face images and different morphing algorithms are used to fuse the face images. The attack potential of the differently generated morphed face images will be quantified to compare the usability of the embeddings for automatically generating a large number of successful Morphing Attacks. For the second objective, we compare the performance of the embeddings of two state-of-the-art face recognition systems with respect to their ability to detect morphed face images. Our results demonstrate that ArcFace and MagFace provide valuable face embeddings for image pre-selection. Various open-source and commercial-off-the-shelf face recognition systems are vulnerable to the generated Morphing Attacks, and their vulnerability increases when image pre-selection is based on embeddings compared to random pairing. In particular, landmark-based closed-source morphing algorithms generate attacks that pose a high risk to any tested face recognition system. Remarkably, more accurate face recognition systems show a higher vulnerability to Morphing Attacks. Among the systems tested, commercial-off-the-shelf systems were the most vulnerable to Morphing Attacks. In addition, MagFace embeddings stand out as a robust alternative for detecting morphed face images compared to the previously used ArcFace embeddings. The results endorse the benefits of face embeddings for more effective image pre-selection for face morphing and for more accurate detection of morphed face images, as demonstrated by extensive analysis of various designed attacks. The MagFace model is a powerful alternative to the often-used ArcFace model in detecting attacks and can increase performance depending on the use case. It also highlights the usability of embeddings to generate large-scale morphed face databases for various purposes, such as training Morphing Attack Detection algorithms as a countermeasure against attacks. [ABSTRACT FROM AUTHOR]

The incidence of candidemia in healthcare centers is associated with high morbidity and mortality. Frequency varies significantly among regions, with some species being more prevalent than others in Latin America. In this study, 191 clinical Candida isolates were collected from a major hospital in Ecuador from January 2019 to February 2020 aiming to assess their prevalence and distribution. After data processing, 168 isolates characterized by the VITEK 2 system were subsequently identified by ITS sequencing. Results showed diverse Candida species distributions, with C. albicans and C. tropicalis being the most prevalent across different clinical sources. In hospitalized individuals, C. tropicalis (38%) and C. albicans (37%) were the most prevalent, followed by, C. parapsilosis (16%), C. glabrata (5%), and other non-Candida albicans (NCA) species (6%). Conversely, C. parapsilosis (48%), C. albicans (20%), and C. glabrata (14%), associated with candidemia, were the most common in blood and CSF. Additionally, uncommon NCA species such as C. haemulonii, C. kefyr, and C. pelliculosa were identified in Ecuador for the first time. Discrepancies in species identification were observed between the VITEK 2 system and ITS sequencing, coinciding at 85%. This highlights the need for ongoing surveillance and identification efforts in Ecuador's clinical and epidemiological settings. [ABSTRACT FROM AUTHOR]

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ObjectivesThe aims of the study were to determine whether mild, occult sleep-disordered breathing (SDB) moderates the efficacy of cognitive behavioral therapy for insomnia (CBTI) in older adults and to explore whether CBTI reduces the number of patients eligible for positive airway pressure (PAP) therapy.MethodsData were analyzed for 134 adults 60 years or older with insomnia and apnea-hypopnea index (AHI) of less than 15 who were randomized to a larger study of CBTI versus a sleep education control. Sleep outcomes (sleep onset latency, total wake time, wake after sleep onset, sleep efficiency, Pittsburgh Sleep Quality Index) were compared between CBTI and control at 6 months using repeated-measures analysis of variance adjusted for baseline values. AHI of 5 or greater versus less than 5 was included as an interaction term to evaluate changes in sleep outcomes. The number of participants at baseline and 6 months with mild SDB for whom insomnia was their only other indication for PAP was also compared between CBTI and control.ResultsAHI status (AHI ≥ 5 [75.5% of participants] versus AHI < 5) did not moderate improvements in sleep associated with CBTI (all p values ≥ .12). Nine (45.0%) of 20 participants with mild SDB for whom insomnia was their only other indication for PAP therapy at baseline no longer had another indication for PAP at 6 months, with no significant difference between CBTI and control.ConclusionsCBTI improves sleep in older veterans with insomnia and untreated mild SDB. Larger trials are needed to assess whether CBTI reduces the number of patients with mild SDB eligible for PAP.

In this contribution, the use of glycidyl methacrylate and styrene copolymers synthesized by nitroxide-mediated polymerization (NMP) as chain extenders of postconsumer Polyethylene terephthalate) waste (r-PET) is described. Our observations revealed that the copolymers synthesized by NMP act as efficient chain extenders for the regeneration of PET waste. Epoxide groups in the copolymers react with PET end reactive groups producing chain extended PET with higher molecular weight and improving performance. The increase in molecular weight of PET waste results in important improvement in both, elongation-at-break, and strength impact. r-PET complex viscosity and rheological moduli are also greatly improved as the epoxide content in the chain extenders increases. The loss tangent and phase angle versus angular frequency plots for chain-extended r-PET reveal that melt elasticity is also improved. These results confirm that use of NMP-synthesized copolymers is a plausible solution for the recycling of PET., INTRODUCTION Polyethylene terephthalate) (PET) is one of the most widely used engineering polymers because of its lightness, low-cost and processing low energy requirements [1]. However, the worldwide excessive production of [...]