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BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Angiomyomas are benign tumors derived from smooth muscle cells of vessels. They are principally a pathology of the peripheral nervous system where they involve cutaneous nerves, causing pain and paresthesia. We present a case of a lateral femoral cutaneous nerve angiomyoma and its surgical treatment. A 24-year-old female presented to clinic with right thigh pain in the distribution of the lateral femoral cutaneous nerve, which had been ongoing and progressive for seven months. There was associated numbness and tingling. A lesion was noted in the anterior subcutaneous tissues of the thigh on contrasted CT and MRI. The patient was taken to the operating room where a pearly white lesion was found within the subcutaneous tissue. No effect was seen with stimulation of the lesion. The lesion was removed en bloc, and pathological analysis revealed an angiomyoma. Post-operatively, the patient reported complete resolution of all symptoms, namely, pain and paresthesia. No similar reports were identified within the literature. Together, angiomyomas have been described within the lower extremities to cause pain and paresthesia. This is the first reported case of an angiomyoma involvement within the lateral femoral cutaneous nerve. Complete surgical resection, in this case, was curative and diagnostic.

The digital transformation of industry and society continues to advance. While some companies are achieving trailblazer status, others are finding it difficult to manage or even initiate the necessary changes. Top-level leaders play a central role in these transformational processes, as they have the opportunity to directly or indirectly influence decisive variables. In this article, we present the results of interviews with 13 digital leaders who have successfully implemented the necessary changes for the digital transformation of their companies. The results of the interviews provide key dimensions for leaders to digitally transform their companies.

This research investigates consumers' responses to products made of recycled ocean plastic. A quantitative study was conducted online with 258 Dutch consumers in which attitudinal and behavioural responses to products made of ocean plastic were investigated. The most important predictors of consumers' purchase intention were anticipated conscience, value for money and perceived functionality. In addition, risks of contamination negatively influenced purchase intention. For willingness-to-pay (WTP) a price premium, anticipated conscience, recognisability and perceived safety appeared to be the most important predictors. Through a cluster analysis, four different consumer groups were identified. Two consumer clusters consisting of ‘sustainability experts’ and the ‘sustainability benevolent’ (59% of our sample) demonstrated a strong interest and a willingness to pay a price premium for these products. When comparing consumers' responses in different product categories, results showed that quality expectations and purchase intention were generally lower for textile products than for durables and fast-moving consumer goods packages. This research contributes to the theoretical understanding of consumer responses to products made of recycled ocean plastic and can help companies to develop strategies to launch such products effectively.

Background Parkinson disease (PD) remains a common neurodegenerative disorder. Functional neurosurgery largely arose with the introduction of deep brain stimulation (DBS) as a potential option for PD unresponsive to medical management. Biomarkers are clinical and laboratory indicators of therapeutic success or failure. Objective To examine the current and published literature relating to the development and use of biomarkers in monitoring and determining the efficacy of DBS in PD. Methods The PubMed database was systematically searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systemic reviews. Studies that examined current or potential biomarkers measurable after DBS were included. Articles from 1952 to date were examined. Results The initial search identified 49 articles. Thirty articles met the inclusion criteria. Articles were subdivided into those addressing biomarkers with proven clinical usefulness and potential biomarkers that have future application. Conclusions Biomarkers have been identified that can help to determine the effect of DBS on patients with PD. Current studies show that there are measured differences in electrophysiologic oscillations, gene expression, neuropeptide levels, metabolic function, inflammatory activity, and others in the central nervous system after DBS in PD. Local field potential and β-band analysis stand as the clinically proven biomarkers of choice for DBS in PD. Many of the identified changes noted could be implemented as clinically useful biomarkers through which DBS may be monitored. Future studies are needed to determine which noted physiologic changes are most appropriately used as biomarkers and in which contexts they are most helpful.

When using an automated system, user trust in the automation is an important factor influencing performance. Prior studies have analyzed trust during supervisory control of automation, and how trust influences reliance: the behavioral correlate of trust. Here, we investigated how reliance on haptic assistance affects performance during shared control with an automated system. Subjects made reaches towards a hidden target using a visual cue and haptic cue (assistance from the automation). We sought to influence reliance by changing the variability of trial-by-trial random errors in the haptic assistance. Reliance was quantified in terms of the subject's position at the end of the reach relative to the two cues. Our results show that subjects aimed more towards the visual cue when the variability of the haptic cue errors increased, resembling cue weighting behavior. Similar behavior was observed both when subjects had explicit knowledge about the haptic cue error variability, as well as when they had only implicit knowledge (from experience). However, the group with explicit knowledge was able to more quickly adapt their reliance on the haptic assistance. The method we introduce here provides a quantitative way to study user reliance on the information provided by automated systems with shared control.

Several clinical trials have demonstrated that advanced neuroimaging can select patients for recanalization therapy in an extended time window. The favorable functional outcomes and safety profile of these studies have led to the incorporation of neuroimaging in endovascular treatment guidelines, and most recently, also extended to decision making on thrombolysis. Two randomized clinical trials have demonstrated that patients who are not amenable to endovascular thrombectomy within 4.5 hours from symptoms discovery or beyond 4.5 hours from the last-known-well time may also be safely treated with intravenous thrombolysis and have a clinical benefit above the risk of safety concerns. With the growing aging population, increased stroke incidence in the young, and the impact of evolving medical practice, healthcare and stroke systems of care need to adapt continuously to provide evidence-based care efficiently. Therefore, understanding and incorporating appropriate screening strategies is critical for the prompt recognition of potentially eligible patients for extended-window intravenous thrombolysis. Here we review the clinical trial evidence for thrombolysis for acute ischemic stroke in the extended time window and provide a review of new enrolling clinical trials that include thrombolysis intervention beyond the 4.5 hour window.

Introduction: In the wake of both the unprecedented nationwide ban on elective surgery during the COVID-19 pandemicand the increased mortality of otolaryngologists and neurosurgeons during this same time period, concern regarding thetiming and safety of neurosurgical intervention for sellar-based pathology has been raised within both the neurosurgical andotolaryngology communities. Methods: A retrospective chart review was performed on all patients who underwent operative intervention for sellar-basedpathology from March 12 to July 1 for both 2019 and 2020. Dates were chosen to align with the Virginia State ofEmergency on March 12 and the multiphase reopening of the public which lasted until July 1. Primary endpoints studied forcomparison included case volume, median time to surgery, and COVID-related mortality. Results: In total, a 26.6% decrease in overall surgical case volume occurred in comparison to the previous year. Astatistically significant decrease in frequency of endonasal surgery was seen from 20 in 2019 to 6 in 2020 ( p = 0.04). Whilemedian time to surgery for pituitary adenomas was unchanged from the previous year (26 days), this data does not takeinto account six patients who electively postponed treatment due to fear of receiving medical care during the pandemic.Among 2,795 COVID-19 patients treated in our institution, only one patient had a pituitary tumor. Here, treatment wasdelayed by 81 days. For emergent cases, such as pituitary apoplexy, surgeons increased utilization of the microscope as ameans to reduce the number of personnel exposed. Finally, our practice had no COVID-related mortality for patientsundergoing sellar-based surgery. Conclusion: The COVID-19 pandemic did not delay time to treatment for emergent presentations of vision loss or pituitaryapoplexy. In these instances, our department followed strict institutional policy regarding use of proper PPE, as well asminimization of hospital personnel exposure. On an outpatient basis, the pandemic did cause a noticeable delay in time totreatment;however, patients' outcomes were unaffected. Close patient monitoring was achieved via utilization oftelemedicine to trend hormone levels and assess development of related symptoms. Finally, decreases in overall casevolume are likely due to ongoing cultural avoidance of seeking medical care, while deferment of endonasal surgery may beattributed to a concern for greater mortality for endonasal procedures.

The EXperiment for Cryogenic Large-Aperture Intensity Mapping (EXCLAIM) is a cryogenic balloon-borne instrument that will map carbon monoxide and singly-ionized carbon emission lines across redshifts from 0 to 3.5, using an intensity mapping approach. EXCLAIM will broaden our understanding of these elemental and molecular gases and the role they play in star formation processes across cosmic time scales. The focal plane of EXCLAIM's cryogenic telescope features six {\mu}-Spec spectrometers. {\mu}-Spec is a compact, integrated grating-analog spectrometer, which uses meandered superconducting niobium microstrip transmission lines on a single-crystal silicon dielectric to synthesize the grating. It features superconducting aluminum microwave kinetic inductance detectors (MKIDs), also in a microstrip architecture. The spectrometers for EXCLAIM couple to the telescope optics via a hybrid planar antenna coupled to a silicon lenslet. The spectrometers operate from 420 to 540 GHz with a resolving power R={\lambda}/{\Delta}{\lambda}=512 and employ an array of 355 MKIDs on each spectrometer. The spectrometer design targets a noise equivalent power (NEP) of 2x10-18W/\sqrt{Hz} (defined at the input to the main lobe of the spectrometer lenslet beam, within a 9-degree half width), enabled by the cryogenic telescope environment, the sensitive MKID detectors, and the low dielectric loss of single-crystal silicon. We report on these spectrometers under development for EXCLAIM, providing an overview of the spectrometer and component designs, the spectrometer fabrication process, fabrication developments since previous prototype demonstrations, and the current status of their development for the EXCLAIM mission., Comment: SPIE Astronomical Telescope + Instrumentation

Taking care of products is an important aspect of sustainable consumer behaviour, because it is an appropriate approach to prolong products' lifetimes. Although consumers in general agree on this and demonstrate a general motivation to take care of their products, previous research has shown that they struggle to repair, maintain or treat their products carefully in daily life. Design has the potential to increase consumers' product care activities, but more knowledge and distinct strategies are needed by designers to purposefully design for this behaviour. We used three different approaches – a workshop with design students, an analysis of already existing products and services that have implemented aspects of product care, and an ideation session – to create eight strategies and 24 sub-strategies that can stimulate product care through design. These eight strategies are informing, enabling, social connections, appropriation, control, awareness, antecedents & consequences, and reflecting. To support designers in the implementation of these strategies, we transferred these strategies into a toolkit, which can be used in the product development process of different kinds of products. This paper describes the development of the product care strategies as well as the Product Care Toolkit.

Objective: A role of the motor cortex in tremor generation in essential tremor (ET) is assumed, yet the directionality of corticomuscular coupling is unknown. Our aim is to clarify the role of the motor cortex. To this end we also study ‘familial cortical myoclonic tremor with epilepsy’ (FCMTE) and slow repetitive voluntary movements with a known cortical drive. Methods: Directionality of corticomuscular coupling (EEG-EMG) was studied with renormalized partial directed coherence (rPDC) during tremor in 25 ET patients, 25 healthy controls (mimicked) and in seven FCMTE patients; and during a self-paced 2 Hz task in eight ET patients and seven healthy controls. Results: Efferent coupling around tremor frequency was seen in 33% of ET patients, 45.5% of healthy controls, all FCMTE patients, and, around 2 Hz, in all ET patients and all healthy controls. Ascending coupling, seen in the majority of all participants, was weaker in ET than in healthy controls around 5–6 Hz. Conclusions: Possible explanations are that tremor in ET results from faulty subcortical output bypassing the motor cortex; rate-dependent transmission similar to generation of rhythmic movements; and/or faulty feedforward mechanism resulting from decreased afferent (sensory) coupling. Significance: A linear cortical drive is lacking in the majority of ET patients.

Product care is defined as all activities initiated by consumers that encourage an extension of product lifetimes, such as repair, maintenance, and/or careful handling. A product care scale was developed and validated in a set of four related studies. In study 1, we asked experts to examine the face validity of a set of 35 items. In study 2, we reduced the initial set of items to 10 items using exploratory factor analysis. A subsequent confirmatory factor analysis supported a three-factor solution. Study 3, a nomological network study, demonstrated that the construct measured by our scale is related but still distinguishable from existing concepts, such as frugality, use innovativeness and attachment towards the product. Study 4 was a known-groups test with participants from two different countries and with various previous experiences in repairing. The final 10-item product care scale includes three factors: relevance, easiness and positive experience.

Background: Taking care of products is a relevant approach to prolong products’ lifetimes and retain their desired level of performance, and is thus an important aspect of sustainable consumer behaviour. Although consumers have a general motivation to take care of their products, previous research has shown that they struggle to repair, maintain or treat their products carefully in daily life. Design has the potential to increase consumers’ product care activities, but designers need more knowledge and distinct strategies to evoke this product care behaviour with consumers. Methods: By the means of a multi-method approach—individual and group brainstorming sessions as well as an analysis of existing solutions—we created a large number of ideas on how to stimulate product care among consumers. Results: We were able to summarize these ideas in a clustering session into eight strategies and 24 sub-strategies that can foster product care through design. These eight strategies are: social connections, informing, enabling, appropriation, control, awareness, antecedents & consequences, and reflecting. The integration of the consumer perspective into strategies for product care extends currently known design strategies for repair and maintenance. To support designers in the implementation of these strategies, we developed a toolkit that can be used in the product development process of different product categories. Conclusions: This paper identifies product care strategies that have a distinct focus on the consumers’ perspective of sustainable behaviour and that can be stimulated through design. These rather psychologically-driven strategies thereby complement existing technology- and product-oriented design strategies. Furthermore, to facilitate implementation, a design toolkit has been developed that points to key requirements in practice.

Accurate and swift tuning of joint impedance is crucial to perform movement and interaction with our environment. Time-varying system identification enables quantification of joint impedance during movement. Many methods have been developed over the years, each with their own mathematical approach and underlying assumptions. Yet, for the identification of joint impedance, a systematic comparison revealing each method's unique strengths and weaknesses, is lacking. Here, we propose a quantitative framework to compare these methods. The framework is used to review five time-varying system identification methods using both simulated data and experimental data. These methods included three time-domain methods: ensemble, short data segment, and basis impulse response function; and two frequency-domain methods: ensemble spectral, and kernel-based regression. In the simulation study, joint stiffness – the static component of impedance – was simulated as a square wave to mimic the most extreme case of time-varying behavior. The identification results were compared based on the (1) variance accounted for (VAF), (2) bias, (3) random, and (4) total estimation error with respect to the simulated joint stiffness; and (5) rise time between two stiffness levels. In the experimental study, human ankle joint impedance was identified. Identification performance was compared using the variability in estimating joint stiffness – representative of the random error – and VAF. The performance metrics revealed distinct identification properties for each method. Therefore, researchers must make a well-justified decision which method is most appropriate for their application. The combination of simulation and experimental work with extensive performance quantification creates a framework for quantitative assessment of newly developed time-varying system identification methods.

The EXperiment for Cryogenic Large-Aperture Intensity Mapping (EXCLAIM) is a balloon-borne far-infrared telescope that will survey star formation history over cosmological time scales to improve our understanding of why the star formation rate declined at redshift z < 2, despite continued clustering of dark matter. Specifically,EXCLAIM will map the emission of redshifted carbon monoxide and singly-ionized carbon lines in windows over a redshift range 0 < z < 3.5, following an innovative approach known as intensity mapping. Intensity mapping measures the statistics of brightness fluctuations of cumulative line emissions instead of detecting individual galaxies, thus enabling a blind, complete census of the emitting gas. To detect this emission unambiguously, EXCLAIM will cross-correlate with a spectroscopic galaxy catalog. The EXCLAIM mission uses a cryogenic design to cool the telescope optics to approximately 1.7 K. The telescope features a 90-cm primary mirror to probe spatial scales on the sky from the linear regime up to shot noise-dominated scales. The telescope optical elements couple to six ��-Spec spectrometer modules, operating over a 420-540 GHz frequency band with a spectral resolution of 512 and featuring microwave kinetic inductance detectors. A Radio Frequency System-on-Chip (RFSoC) reads out the detectors in the baseline design. The cryogenic telescope and the sensitive detectors allow EXCLAIM to reach high sensitivity in spectral windows of low emission in the upper atmosphere. Here, an overview of the mission design and development status since the start of the EXCLAIM project in early 2019 is presented., SPIE Astronomical Telescopes + Instrumentation. arXiv admin note: substantial text overlap with arXiv:1912.07118

This research explores a new pathway to improve consumer acceptance of refurbished products that is inspired by the positive evocations of other used products, such as antique products. Currently, the prior use and age of refurbished products make them a less desirable option because they are perceived to be of lower quality, to have a reduced performance and to be out of fashion more quickly than new products. In contrast, antiques are associated with durability, uniqueness and timelessness despite their prior use and considerable age. In 21 in-depth interviews with consumers, we compared refurbished products with antiques and explored whether refurbished products with a design style evoking the past – the neo-retro style – can lead to more positive associations than refurbished products with a prototypical design style. Our findings provided preliminary support for the value of a neo-retro design style for improving consumers' evaluations of refurbished products. Refurbished products and antiques differ in age, technology and the purpose of having them. Antiques have an emotional value and are kept because of the story and historic values, the appearance and/or durability refurbished products are kept for purely functional reasons. Similar to antiques, refurbished products following a neo-retro design style do not only evoke more positive associations with old products, such as feelings of nostalgia but can also decrease risks associated with refurbished products as they are perceived to be of higher quality and more durable than refurbished products following a prototypical design style.

Skeletal muscles generate force, enabling movement through a series of fast electro-mechanical activations coordinated by the central nervous system. Understanding the underlying mechanism of such fast muscle dynamics is essential in neuromuscular diagnostics, rehabilitation medicine and sports biomechanics. The unique combination of electromyography (EMG) and ultrafast ultrasound imaging (UUI) provides valuable insights into both electrical and mechanical activity of muscle fibers simultaneously, the excitation-contraction (E-C) coupling. In this feasibility study we propose a novel non-invasive method to simultaneously track the propagation of both electrical and mechanical waves in muscles using high-density electromyography and ultrafast ultrasound imaging (5000 fps). Mechanical waves were extracted from the data through an axial tissue velocity estimator based on one-lag autocorrelation. The E-C coupling in electrically evoked twitch contractions of the Biceps Brachii in healthy participants could successfully be tracked. The excitation wave (i.e. action potential) had a velocity of 3.9±0.5ms−1 and the subsequent mechanical (i.e. contraction) wave had a velocity of 3.5±0.9ms−1. The experiment showed evidence that contracting sarcomeres that were already activated by the action potential (AP) pull on sarcomeres that were not yet reached by the AP, which was corroborated by simulated contractions of a newly developed multisegmental muscle fiber model, consisting of 500 sarcomeres in series. In conclusion, our method can track the electromechanical muscle dynamics with high spatio-temporal resolution. Ultimately, characterizing E-C coupling in patients with neuromuscular diseases (e.g. Duchenne or Becker muscular dystrophy) may assess contraction efficiency, monitor the progression of the disease, and determine the efficacy of new treatment options.

This work describes the optical design of the EXperiment for Cryogenic Large-Aperture Intensity Mapping (EXCLAIM). EXCLAIM is a balloon-borne telescope that will measure integrated line emission from carbon monoxide (CO) at redshifts z < 1 and ionized carbon ([CII]) at redshifts z = 2.5-3.5 to probe star formation over cosmic time in cross-correlation with galaxy redshift surveys. The EXCLAIM instrument will observe at frequencies of 420--540 GHz using six microfabricated silicon integrated spectrometers with spectral resolving power R = 512 coupled to kinetic inductance detectors (KIDs). A completely cryogenic telescope cooled to a temperature below 5 K provides low-background observations between narrow atmospheric lines in the stratosphere. Off-axis reflective optics use a $90$-cm primary mirror to provide 4.2' full-width at half-maximum (FWHM) resolution at the center of the EXCLAIM band over a field of view of 22.5'. Illumination of the 1.7 K cold stop combined with blackened baffling at multiple places in the optical system ensures low (< -40 dB) edge illumination of the primary to minimize spill onto warmer elements at the top of the dewar., 15 pages, 8 figures