Ambient heat exposure patterns and emergency department visits and hospitalizations among medicare beneficiaries 2008-2019.

OBJECTIVE: To assess the association between ambient heat and all-cause and cause-specific emergency department (ED) visits and acute hospitalizations among Medicare beneficiaries in the conterminous United States. DESIGN: Retrospective cohort study. SETTING: Conterminous US from 2008 and 2019. PARTICIPANTS: 2% random sample of all Medicare fee-for-service beneficiaries eligible for Parts A, B, and D. MAIN OUTCOME MEASURES: All-cause and cause-specific (cardiovascular, renal, and heat-related) ED visits and unplanned hospitalizations were identified using primary ICD-9 or ICD-10 diagnosis codes. We measured the association between ambient temperature - defined as daily mean temperature percentile of summer (June through September) - and the outcomes. Hazard ratios and their associated 95% confidence intervals were estimated using multivariable Cox proportional hazards regression, adjusting for individual level demographics, comorbidities, healthcare utilization factors and zip-code level social factors. RESULTS: Among 809,636 Medicare beneficiaries (58% female, 81% non-Hispanic White, 24% <65), older beneficiaries (aged ≥65) exposed to >95th percentile temperature had a 64% elevated adjusted risk of heat-related ED visits (HR [95% CI], 1.64 [1.46,1.85]) and a 4% higher risk of all-cause acute hospitalization (1.04 [1.01,1.06]) relative to <25th temperature percentile. Younger beneficiaries (aged <65) showed increased risk of heat-related ED visits (2.69 [2.23,3.23]) and all-cause ED visits (1.03 [1.01,1.05]). The associations with heat related events were stronger in males and individuals dually eligible for Medicare and Medicaid. No significant differences were observed by climatic region. We observed no significant relationship between temperature percentile and risk of CV-related ED visits or renal-related ED visits. CONCLUSIONS: Among Medicare beneficiaries from 2008 to 2019, exposure to daily mean temperature ≥ 95th percentile was associated with increased risk of heat-related ED visits, with stronger associations seen among beneficiaries <65, males, and patients with low socioeconomic position. Further longitudinal studies are needed to understand the impact of heat duration, intensity, and frequency on cause-specific hospitalization outcomes.

Ambient Heat and Risk of Serious Hypoglycemia in Older Adults With Diabetes Using Insulin in the U.S. and Taiwan: A Cross-National Case-Crossover Study.

OBJECTIVE: To measure the association between ambient heat and hypoglycemia-related emergency department visit or hospitalization in insulin users. RESEARCH DESIGN AND METHODS: We identified cases of serious hypoglycemia among adults using insulin aged ≥65 in the U.S. (via Medicare Part A/B/D-eligible beneficiaries) and Taiwan (via National Health Insurance Database) from June to September, 2016-2019. We then estimated odds of hypoglycemia by heat index (HI) percentile categories using conditional logistic regression with a time-stratified case-crossover design. RESULTS: Among ∼2 million insulin users in the U.S. (32,461 hypoglycemia case subjects), odds ratios of hypoglycemia for HI >99th, 95-98th, 85-94th, and 75-84th percentiles compared with the 25-74th percentile were 1.38 (95% CI, 1.28-1.48), 1.14 (1.08-1.20), 1.12 (1.08-1.17), and 1.09 (1.04-1.13) respectively. Overall patterns of associations were similar for insulin users in the Taiwan sample (∼283,000 insulin users, 10,162 hypoglycemia case subjects). CONCLUSIONS: In two national samples of older insulin users, higher ambient temperature was associated with increased hypoglycemia risk.

Computational models can distinguish the contribution from different mechanisms to familiarity recognition.

Familiarity is the strange feeling of knowing that something has already been seen in our past. Over the past decades, several attempts have been made to model familiarity using artificial neural networks. Recently, two learning algorithms successfully reproduced the functioning of the perirhinal cortex, a key structure involved during familiarity: Hebbian and anti-Hebbian learning. However, performance of these learning rules is very different from one to another thus raising the question of their complementarity. In this work, we designed two distinct computational models that combined Deep Learning and a Hebbian learning rule to reproduce familiarity on natural images, the Hebbian model and the anti-Hebbian model, respectively. We compared the performance of both models during different simulations to highlight the inner functioning of both learning rules. We showed that the anti-Hebbian model fits human behavioral data whereas the Hebbian model fails to fit the data under large training set sizes. Besides, we observed that only our Hebbian model is highly sensitive to homogeneity between images. Taken together, we interpreted these results considering the distinction between absolute and relative familiarity. With our framework, we proposed a novel way to distinguish the contribution of these familiarity mechanisms to the overall feeling of familiarity. By viewing them as complementary, our two models allow us to make new testable predictions that could be of interest to shed light on the familiarity phenomenon.

Influence of interactive effects on long-term population trajectories in multispecies reintroductions.

Reintroduced populations are typically considered to progress through establishment, growth, and regulatory phases. However, most reintroduction programs do not monitor intensively enough to test this conceptual model. We studied population indices derived from track activity of 4 threatened species (greater bilby [Macrotis lagotis], burrowing bettong [Bettongia lesueur], greater stick-nest rat [Leporillus conditor], and Shark Bay bandicoot [Perameles bougainville]) over 23 years after multiple reintroductions of each species in arid Australia. We compared population trajectories among species and investigated the effect of time and environmental variables. All species bred immediately after release, and the growth phase lasted 3-16 years, varying markedly among but not within species. The end of the growth phase was characterized by an obvious peak in population density followed by either a catastrophic decline and sustained low density (bettongs), a slow decline to extirpation after 20 years (stick-nest rat), or a slight decline followed by irregular fluctuations (bilby and bandicoot). Minor fluctuations were related to environmental variables, including 12-month cumulative rainfall and lagged summer maximum temperatures. Three of the 4 species did not reach a regulation phase, even after 23 years, possibly due to interspecific competition and trophic cascades triggered by predator removal and multispecies reintroductions. Bilbies and bandicoots exhibited a second growth phase 18 years after reintroduction, likely caused by high rainfall and increased resources following the population crash of overabundant bettongs. Our results suggest that assemblages within multispecies reintroductions demonstrate high variability in population trajectories due to interactive effects. Intensive monitoring to assess population viability may require decades, particularly where multiple species are reintroduced, release sites are confined, and the climate is unpredictable. Intensive monitoring also allows for adaptive management to prevent precipitous population declines. Practitioners should not assume reintroduced species pass through predictable postrelease population phases or that viability is assured after a certain period.

Influencia de los efectos interactivos sobre la trayectoria a largo plazo de las poblaciones en reintroducciones de múltiples especies Resumen Comúnmente se considera que las poblaciones reintroducidas progresan cuando se establecen, crecen y atraviesan fases regulatorias. Sin embargo, casi todos los programas de reintroducción no monitorean lo suficiente para evaluar este modelo conceptual. Estudiamos los índices poblacionales derivados de la actividad de rastreo de cuatro especies amenazadas (Macrotis lagotis, Bettongia lesueur, Leporillus conditor, y Perameles bougainville) más de 23 años después de varias reintroducciones de cada especie en las zonas áridas de Australia. Comparamos las trayectorias poblacionales entre especies e investigamos el efecto del tiempo y las variables ambientales. Todas las especies se reprodujeron inmediatamente después de la liberación, y la fase de crecimiento duró entre 3 y 16 años, con una variación marcada entre, pero no dentro de las especies. El final de la fase de crecimiento se caracterizó por un pico obvio en la densidad poblacional seguido de una declinación catastrófica o una baja densidad sostenida (B. lesueur), una declinación lenta ante la extirpación 20 años después (L. conditor) o una declinación leve seguida de fluctuaciones irregulares (M. lagotis y P. bougainville). Las fluctuaciones menores estuvieron relacionadas con las variables ambientales, incluyendo la precipitación acumulada de 12 meses y el retraso en las temperaturas máximas de verano. Tres de las cuatro especies no llegaron a la fase regulatoria, incluso después de 23 años, posiblemente por la competencia interespecífica y las cascadas tróficas causadas por la eliminación de depredadores y la reintroducción de varias especies. M. lagotis y P. bougainville exhibieron una segunda fase de crecimiento 18 años después de la reintroducción, probablemente causada por la precipitación elevada y el incremento de recursos después de la crisis poblacional por sobreabundancia de B. lesueur. Nuestros resultados sugieren que los conjuntos dentro de la reintroducción de múltiples especies demuestran una gran variabilidad en las trayectorias poblacionales debido a los efectos interactivos. El monitoreo intenso para evaluar la viabilidad poblacional puede llevar varias décadas, particularmente cuando se reintroducen varias especies, en donde los sitios de liberación están confinados y en donde el clima es impredecible. El monitoreo intensivo también permite que el manejo adaptativo prevenga una declinación poblacional precipitada. Quienes practican la conservación no deberían asumir que una especie reintroducida atraviesa fases predecibles después de la liberación o que la viabilidad está asegurada después de cierto periodo.

An independent audit of electroconvulsive therapy patient information leaflets in Northern Ireland, Scotland and Wales.

OBJECTIVES: To evaluate the accuracy of patient information leaflets about electroconvulsive therapy (ECT) used in Northern Ireland, Scotland and Wales, and their compliance with the principle of informed consent. DESIGN AND METHODS: To replicate an audit in England, Freedom of Information Act requests were sent to the 26 providers of ECT for their ECT patient information leaflet. These were scored, by two independent raters, on the same 40-item accuracy measure used in the England audit. RESULTS: The number of accurate statements (out of a possible 29) ranged from seven to 20, with a mean of 16.9. The most frequently omitted statements included: cardiovascular risks (mentioned by five leaflets), that it is not known how ECT works (3), risk of mortality (2), risks from multiple general anaesthetic procedures (2), how to access a legal advocate (2) and that that there is no evidence of long-term benefits (1). The leaflets made between six and nine inaccurate statements (out of 11) with a mean of 7.0. Nineteen minimised memory loss, blamed the memory loss on depression, claimed that ECT is the 'most effective treatment' and asserted it has very high response rates without mentioning similar placebo response rates. All 23 leaflets wrongly told patients that ECT saves lives. CONCLUSIONS: Electroconvulsive therapy information leaflets in these three nations are barely more accurate than those in England and do not comply with the ethical principle of informed consent. Patients and families across the UK are systematically being misled about the risks they are taking and the limited nature of ECT's benefits.

The need for antidepressant withdrawal support services: Recommendations from 708 patients.

Approximately half of the tens of millions of people currently taking antidepressants will experience withdrawal symptoms when they try to reduce or come off them. Nearly half of these describe their symptoms as severe in surveys. Many prescribing doctors seem ill-informed and unprepared to provide effective discontinuation advice and support, often misdiagnosing withdrawal as a relapse of depression or anxiety. 708 members of online support groups for people on antidepressants, from 31 countries, completed a sentence in an online survey: 'A public health service to help people come off antidepressants should include ................'. Two independent researchers categorised their responses into themes, and then reached consensus via discussion. Seven themes emerged: 'Prescriber Role', 'Information', 'Other Supports/Services', 'Strong Negative Feelings re Doctors/Services etc.', Informed Consent When Prescribed', 'Drug Companies' and: 'Public Health Campaign'. The most frequently mentioned requirements of the Prescriber Role were that prescribers be properly informed, provide small doses/liquid/tapering strips, develop a withdrawal plan and believe patients about their withdrawal experiences. The most frequently recommended other services were psychotherapy/counselling, support groups, patient led/informed services, nutrition advice, 24-hour crisis support and 'holistic/lifestyle' approaches. Many respondents were angry about how uninformed their doctors were and how they had been treated.

Tuning Amorphous Selenium Composition with Tellurium to Improve Quantum Efficiency at Long Wavelengths and High Applied Fields.

Amorphous selenium (a-Se) is a large-area compatible photoconductor that has received significant attention toward the development of UV and X-ray detectors for a wide range of applications in medical imaging, life science, high-energy physics, and nuclear radiation detection. A subset of applications require detection of photons with spectral coverage from UV to infrared wavelengths. In this work, we present a systematic study utilizing density functional theory simulations and experimental studies to investigate optical and electrical properties of a-Se alloyed with tellurium (Te). We report hole and electron mobilities and conversion efficiencies for a-Se1-xTex (x = 0, 0.03, 0.05, 0.08) devices as a function of applied field, along with band gaps and comparisons to previous studies. For the first time, these values are reported at high electric field (>10 V/µm), demonstrating recovery of quantum efficiency in Se-Te alloys. A comparison to the Onsager model for a-Se demonstrates the strong field dependence in the thermalization length and expands on the role of defect states in device performance.

Designing withdrawal support services for antidepressant users: Patients' views on existing services and what they really need.

BACKGROUND: Public Health England has recommended that services be put in place to support people who choose to withdraw from antidepressants because of a current gap. This study aims to explore the views of members of online withdrawal peer-support groups about existing healthcare and what additional support is needed. METHODS: The administrators of 15 online support groups for people stopping antidepressants were asked to advertise an online survey to their members. The survey, which was online from May 2021 to April 2022, was completed by 1276 people from 49 countries. RESULTS: 71% of respondents found their doctors' advice unhelpful (57% 'very unhelpful') regarding stopping an antidepressant; the main reasons being 'Recommended a reduction rate that was too quick for me', 'Not familiar enough with withdrawal symptoms to advise me' and 'Suggested stopping antidepressants would not cause withdrawal symptoms'. One in three did not seek advice from their prescriber when deciding whether to withdraw, with the main reasons being 'I felt they would not be supportive' (58%) and 'I felt that they didn't have the expertise to help me' (51%). The most common prescriber responses to those who did seek advice was 'Suggested a quick withdrawal schedule' (56%) and 'Not supportive and offered no guidance' (27%). The most common discontinuation periods recommended by doctors were one month (23%) and two weeks (19%). A range of potential professional services were rated 'very useful', most frequently: 'Access to smaller doses (e.g. tapering strips, liquid, smaller dose tablets) to ensure gradual reduction' (88%) and 'A health professional providing a personalised, flexible reduction plan' (79%). LIMITATIONS: This was a convenience sample, which may have been biased towards people who took longer to withdraw, and experienced more withdrawal symptoms, than antidepressant users in general. Black and ethnic minority people, and people without access to the internet, were underrepresented. CONCLUSIONS: Most participants reported their prescribers were unable to help them safely stop antidepressants, compelling them to turn to online peer-support groups instead. Our findings indicate, in keeping with previous studies, that clinicians require upskilling in safe tapering of antidepressants, and that patients need specialised services to help them stop safely.

pH-Responsive Polymer Implants for the Protection of Native Mammals: Assessment of Material Properties and Poison Incorporation on Performance.

Efforts to mitigate the effects of feral cats through the management of remnant or reintroduced populations of threatened species, are often unsuccessful due to predation by control-averse feral cats, or 'problem individuals'. In order to target these animals, we have developed the Population Protecting Implant (PPI). PPIs are designed to be implanted subcutaneously in a native animal. If the animal is preyed upon, and the implant ingested by a feral cat, release of a toxic payload is triggered in the acidic stomach environment and the problem individual is eliminated. We introduce the first toxic implant incorporating the poison sodium fluoroacetate. Manufactured via fluidised-bed spray coating, toxic implants exhibited uniform reverse enteric coatings and low intra-batch variation. Toxic implants were found to exhibit favourable stability at subcutaneous pH in vitro, and rapidly release their toxic payload in vitro at gastric pH. However, limited stability was demonstrated in rats in vivo (~39-230 d), due to the use of a filament scaffold to enable coating and was likely exacerbated by metachromatic interactions caused by 1080. This work highlights that future development of the PPIs should primarily focus on removal of the filament scaffold, to afford implants with increased in vivo stability.

Pupil response speed as a marker of cognitive fatigue in early Multiple Sclerosis☆.

CONTEXT: Cognitive fatigue (CF) is a disabling symptom frequently reported by patients with Multiple Sclerosis (pwMS). Whether pwMS in the early disease stages present an increased sensitivity to fatigue induction remains debated. Objective measures of CF have been validated neither for clinical nor research purposes. This study aimed at (i) assessing how fatigue induction by manipulation of cognitive load affects subjective fatigue and behavioural performance in newly diagnosed pwMS and matched healthy controls (HC); and (ii) exploring the relevance of eye metrics to describe CF in pwMS. METHODS: Nineteen pwMS with disease duration < 5 years and 19 matched HC participated to this study. CF was induced with a dual-task in two separate sessions with varying cognitive load (High and Low cognitive load conditions, HCL and LCL). Accuracy, reaction times (RTs), subjective fatigue and sleepiness states were assessed. Bayesian Analyses of Variance for repeated measures (rmANOVA) explored the effects of time, group and load condition on the assessed variables. Eye metrics (number of long blinks, pupil size and pupil response speed: PRS) were obtained during the CF task for a sub-sample (16 pwMS and 15 HC) and analysed with Generalized Linear Mixed Models (GLMM). RESULTS: Performance (accuracy and RTs) was lower in the HCL condition and accuracy decreased over time (BFsincl > 100) while RTs did not significantly vary. Performance over task and conditions followed the same pattern of evolution across groups (BFsincl < 0.08) suggesting that pwMS did not show increased alteration of performance during fatigue induction. Regarding subjective state, both fatigue and sleepiness increased following the task (BFsincl > 15), regardless of condition and group (BFsincl < 3). CF in pwMS seems to be associated with PRS, as PRS decreased during the task amongst pwMS only and especially in the HCL condition (all p < .05). A significant Condition*Group interaction was observed regarding long blinks (p < .0001) as well as an expected effect of cognitive load condition on pupil diameter (p < .01). CONCLUSION: These results suggest that newly diagnosed pwMS and HC behave similarly during fatigue induction, in terms of both performance decrement and accrued fatigue sensation. Eye metric data further reveal a susceptibility to CF in pwMS, which can be objectively measured.

How important are informed consent, informed choice, and patient-doctor relationships, when prescribing antipsychotic medication?

BACKGROUND: Antipsychotic medications (APs) are used for people with psychosis diagnoses and, increasingly for other problems and groups. AIMS: This study examines how APs are prescribed, from the perspective of recipients. METHODS: 757 people, from 30 countries, responded to questions about their experiences with APs, in an online survey. RESULTS: Most (70%) were told nothing about adverse effects. Fewer than 2% recalled being told about the risks of diabetes, suicidality, sexual dysfunction, or reduced life span. None recalled being told about reduced brain volume or withdrawal effects. Only 28% recalled being offered other treatments; with only 14% offered talking therapies. 46% were not told how long to take the APs; and, of those who were told something, 48% were told to take them forever. Most respondents (76%) were not told how APs work. Only 19% were satisfied with the prescribing process, and only 25% reported a good, or very good, relationship with the prescriber. Information, satisfaction with the process, and the prescriber relationship were all positively related to three self-reported outcomes: reduction of problems the drugs were prescribed for, general helpfulness, and quality of life. CONCLUSIONS: Steps need to be taken to ensure people prescribed antipsychotics are fully informed, especially about adverse effects and alternatives.

The experiences of 585 people when they tried to withdraw from antipsychotic drugs.

Introduction: Many recipients of antipsychotic drugs try to stop taking them, primarily because of distressing adverse effects. Little research has been undertaken into the withdrawal symptoms that ensue. Methods: In an online survey 585 antipsychotic users, from 29 countries, who had tried to stop taking the drugs, were asked specific questions about the process and the open question: 'What were the effects of withdrawing from the medication?' 44% had a diagnosis in the 'schizophrenia' spectrum. Results: Responding to specific questions, 72% reported classical withdrawal effects of the kind associated with other central nervous system medications, including nausea, tremors, anxiety, agitation and headaches. 52% of these categorized those effects as 'severe'. 26% had tried four or more times to discontinue, and 23% took at least one year to successfully withdraw completely. In response to the open question, 73% reported one or more withdrawal effects, most frequently, insomnia, nervousness and extreme feelings; 26% reported one or more positive outcomes, most frequently more energy/alive and clearer thinking; and 18% reported psychosis. Conclusion: These findings are consistent with a small but growing body of literature on this topic. Prescribers need to inform themselves about the nature, frequency and intensity of withdrawal effects from APs, and about withdrawal psychosis. National guidelines, professional bodies' statements, and drug company information urgently need to be updated to prevent the suffering that can occur when withdrawal is minimised, misunderstood or unsupported.

Observation of solid-state bidirectional thermal conductivity switching in antiferroelectric lead zirconate (PbZrO3).

Materials with tunable thermal properties enable on-demand control of temperature and heat flow, which is an integral component in the development of solid-state refrigeration, energy scavenging, and thermal circuits. Although gap-based and liquid-based thermal switches that work on the basis of mechanical movements have been an effective approach to control the flow of heat in the devices, their complex mechanisms impose considerable costs in latency, expense, and power consumption. As a consequence, materials that have multiple solid-state phases with distinct thermal properties are appealing for thermal management due to their simplicity, fast switching, and compactness. Thus, an ideal thermal switch should operate near or above room temperature, have a simple trigger mechanism, and offer a quick and large on/off switching ratio. In this study, we experimentally demonstrate that manipulating phonon scattering rates can switch the thermal conductivity of antiferroelectric PbZrO3 bidirectionally by -10% and +25% upon applying electrical and thermal excitation, respectively. Our approach takes advantage of two separate phase transformations in PbZrO3 that alter the phonon scattering rate in different manners. In this study, we demonstrate that PbZrO3 can serve as a fast (<1 second), repeatable, simple trigger, and reliable thermal switch with a net switching ratio of nearly 38% from ~1.20 to ~1.65 W m-1 K-1.

Imaging Insights Into Abdominal Wall Function.

Purpose: The successful repair of any complex ventral hernia requires a thorough understanding of the underlying anatomical defect and its functional context. We describe an improved "functional" approach to CT imaging of the abdominal wall that can facilitate this understanding and assist surgical planning. Methods: This invited article reports the observational experience gained from the functional abdominal wall CT examinations of 88 patients who underwent complex ventral hernia repair using pre-operative Botulinum toxin A (BTA) infiltration of the lateral oblique abdominal muscles as well as a further eight patients with diastasis rectus abdominis who were examined to exclude ventral hernia. Results: The use of a functional CT protocol which supplements resting images with additional "crunching" images (acquired with the abdominal wall muscles all strongly contracted) can significantly improve the demonstration of ventral hernia defects. Crunching acquisitions can also help differentiate true hernias from dysfunctional bulges, identify muscle denervation or atrophic changes, reveal otherwise occult hernias that may be missed on resting or Valsalva images alone, and assist the pre-operative assessment of BTA effect. Conclusion: A more functional approach to pre-operative CT imaging of the abdominal wall can significantly improve the understanding of complex ventral hernia defects and help formulate effective surgical plans that achieve low recurrence rates and good functional outcomes.