Enhanced mixing across the gyre boundary at the Gulf Stream front.

The Gulf Stream front separates the North Atlantic subtropical and subpolar ocean gyres, water masses with distinct physical and biogeochemical properties. Exchange across the front is believed to be necessary to balance the freshwater budget of the subtropical gyre and to support the biological productivity of the region; however, the physical mechanisms responsible have been the subject of long-standing debate. Here, the evolution of a passive dye released within the north wall of the Gulf Stream provides direct observational evidence of enhanced mixing across the Gulf Stream front. Numerical simulations indicate that the observed rapid cross-frontal mixing occurs via shear dispersion, generated by frontal instabilities and episodic vertical mixing. This provides unique direct evidence for the role of submesoscale fronts in generating lateral mixing, a mechanism which has been hypothesized to be of general importance for setting the horizontal structure of the ocean mixed layer. Along the Gulf Stream front in the North Atlantic, these observations further suggest that shear dispersion at sharp fronts may provide a source of freshwater flux large enough to explain much of the freshwater deficit in the subtropical-mode water budget and a flux of nutrients comparable to other mechanisms believed to control primary productivity in the subtropical gyre.

Can consumption of local micronutrient- and absorption enhancer-rich plant foods together with starchy staples improve bioavailable iron and zinc in diets of at-risk African populations?

Iron and zinc deficiencies remain prevalent in developing countries, often due to monotonous starchy diets that are low in bioavailable minerals. This review addresses the question as to whether consumption of starchy staple foods in Africa together with micronutrient-dense and absorption enhancer-rich plant foods can enhance iron and zinc bioavailability in the diets of at-risk populations. While green leafy vegetables (GLVs) fortification of starchy staples can improve mineral contents, especially iron, it may not improve bioavailable iron and zinc, due to GLVs' high contents of mineral absorption inhibitors, notably polyphenols, phytate and calcium. Fruits, although low in minerals, could improve bioavailable iron and zinc in the staples because of their high ascorbic and citric acid and/or ß-carotene contents, which can form soluble chelates with the minerals. More human studies are needed to establish whether such a technology or fortification strategy can improve bioavailable iron and zinc in African-type plant-based diets.

Potential of moringa leaf and baobab fruit food-to-food fortification of wholegrain maize porridge to improve iron and zinc bioaccessibility.

Food-to-food fortification (FtFF) with moringa leaf (iron source) and/or baobab fruit (citric acid and ascorbic acid source) (each 13-15 g/100 g porridge dry basis (db)) was studied to improve iron and zinc nutritive quality in African-type wholegrain maize-based porridges using in vitro dialysability assay. Moringa FtFF decreased percentage and total bioaccessible iron and zinc, by up to 84% and 45%, respectively. Moringa was very high in calcium, approximately 3% db and calcium-iron-phytate complexes inhibit iron bioavailability. Baobab FtFF increased percentage and total bioaccessible iron and zinc, especially in porridges containing carrot + mango (ß-carotene source) and conventionally fortified with FeSO4, by up to 111% and 60%, respectively. The effects were similar to those when ascorbic and citric acids were added as mineral absorption enhancers. While moringa FtFF could be inhibitory to iron and zinc bioavailability in cereal-based porridges, baobab fruit FtFF could improve their bioavailability, especially in combination with conventional iron fortification.

Health-related quality of life outcomes for the LEAP study-CALGB 70305 (Alliance): A lymphedema prevention intervention trial for newly diagnosed breast cancer patients.

BACKGROUND: Lymphedema is an adverse effect of breast cancer treatment that causes swelling and pain in the arm and hand. We tested 2 lymphedema prevention interventions and their impact on health-related quality of life (HRQOL) in a group-randomized trial at 38 cooperative group sites within the United States. METHODS: Patients were recruited before breast surgery. Sites were randomly assigned to education-only (EO) lymphedema prevention or education plus exercise and physical therapy (LEAP). Lymphedema was defined as a ≥10% difference in arm volume at any time from baseline to 18 months postsurgery. HRQOL was assessed using the Functional Assessment of Cancer Therapy-Breast plus 4 lymphedema items (FACT-B+4). Longitudinal mixed model regression analysis, adjusting for key demographic and clinical variables, examined participants' HRQOL by intervention group and lymphedema status. RESULTS: A total of 547 patients (56% LEAP) were enrolled and completed HRQOL assessments. The results revealed no differences between the interventions in preventing lymphedema (P = .37) or HRQOL (FACT-B+4 total score; P = .8777). At 18 months, the presence of lymphedema was associated with HRQOL at borderline significance (P = .0825). However, African American patients reported greater lymphedema symptoms (P = .0002) and better emotional functioning (P = .0335) than patients of other races or ethnicities. Lower HRQOL during the intervention was associated with younger age (P ≤ .0001), Eastern Cooperative Oncology Group performance status >0 (P = .0002), ≥1 positive lymph nodes (P = .0009), having no education beyond high school (P < .0001), having undergone chemotherapy (P = .0242), and having had only axillary node dissection or sentinel node biopsy versus both (P = .0007). CONCLUSION: The tested interventions did not differ in preventing lymphedema or in HRQOL outcomes. African American women reported greater HRQOL impacts due to lymphedema symptoms than women of other races or ethnicities.

A randomized study to prevent lymphedema in women treated for breast cancer: CALGB 70305 (Alliance).

BACKGROUND: Lymphedema affects many women who are treated for breast cancer. We examined the effectiveness of an education-only (EO) versus education plus sleeve compression/exercise intervention (lymphedema education and prevention [LEAP]) on lymphedema incidence and range of motion (ROM) in a group-randomized trial across 38 cooperative group sites. METHODS: The treating institution was randomly assigned to either EO or LEAP by a study statistician. All patients at a treating institution participated in the same intervention (EO or LEAP) to minimize contamination bias. Participants completed surveys, arm volume measurements, and self-reported ROM assessments before surgery and at 12 and 18 months after surgery. Lymphedema was defined as a ≥10% difference in limb volume at any time post-surgery up to 18 months after surgery or diagnosis by a health provider. Cochran-Mantel-Haenszel tests were used to compare lymphedema-free rates between groups, stratified by lymph node surgery type. Self-reported ROM differences were compared between groups. RESULTS: A total of 554 participants (56% LEAP) were included in the analyses. At 18 months, lymphedema-free rates were 58% (EO) versus 55% (LEAP) (P = .37). ROM for both arms was greater in LEAP versus EO at 12 months; by 18 months, most women reported full ROM, regardless of group. In LEAP, only one-third wore a sleeve ≥75% of the time; 50% performed lymphedema exercises at least weekly. CONCLUSION: Lymphedema incidence did not differ by intervention group at 18 months. Poor adherence in the LEAP group may have contributed. However, physical therapy may speed recovery of ROM. Further research is needed to effectively reduce the incidence and severity of lymphedema in patients who have breast cancer.

Modification of the functional properties of hard-to-cook cowpea seed flours and cooked prepared pastes by γ-irradiation.

Cowpeas are an inexpensive source of quality protein but their utilisation is limited by long seed cooking time. This is exacerbated by development of the hard-to-cook (HTC) defect, which also adversely affects starch and protein functionality. Gamma-irradiation can eliminate cowpea seed insect infestation and affects seed functional properties, including reducing cooking time. Hence, the potential of γ-irradiation to modify the starch- and protein-related functionalities of HTC cowpeas was investigated. Gamma-irradiation at approximately 11 kGy was applied to the seeds of two cowpea varieties, differing in HTC susceptibility, where HTC had been induced by high-temperature, high-humidity (HTHH) storage. HTHH storage increased flour pasting peak viscosity by up to 40% in the less susceptible variety and by more than 100% in the more susceptible variety. Gamma-irradiation at least completely reversed this effect, due to starch depolymerisation and debranching. Gamma-irradiation also positively impacted on some protein-related properties adversely affected by HTC; partially reversing the reduction in flour and cooked paste nitrogen solubility index of the HTC-susceptible cowpea, as a result of protein depolymerisation. The multiple benefits of γ-irradiation: disinfection, cooking time reduction and reversing some adverse effects of HTC on functional properties could make it a viable process for improving HTC cowpea quality.

ROTEM as a Predictor of Mortality in Patients With Severe Trauma.

BACKGROUND: Hemorrhage, especially when complicated by coagulopathy, is the most preventable cause of death in trauma patients. We hypothesized that assessing hemostatic function using rotational thromboelastometry (ROTEM) or conventional coagulation tests can predict the risk of mortality in patients with severe trauma indicated by an injury severity score greater than 15. METHODS: We retrospectively reviewed trauma patients with an injury severity score >15 who were admitted to the emergency department between November 2015 and August 2017 in a single level I trauma center. Patients with available ROTEM and conventional coagulation data (partial thromboplastin time [PTT], prothrombin time [PT], and international normalized ratio) were included in the study cohort. Logistic regression was performed to assess the relationship between coagulation status and mortality. RESULTS: The study cohort included 301 patients with an average age of 47 y, and 75% of the patients were males. Mortality was 23% (n = 68). Significant predictors of mortality included abnormal APTEM (thromboelastometry (TEM) assay in which fibrinolysis is inhibited by aprotinin (AP) in the reagent) parameters, specifically a low APTEM alpha angle, a high APTEM clot formation time, and a high APTEM clotting time. In addition, an abnormal international normalized ratio significantly predicted mortality, whereas abnormal PT and PTT did not. CONCLUSIONS: A low APTEM alpha angle, an elevated APTEM clot formation time, and a high APTEM clotting time significantly predicted mortality, whereas abnormal PT and PTT did not appear to be associated with increased mortality in this patient population. Viscoelastic testing such as ROTEM appears to have indications in the management and stabilization of trauma patients.

What is food-to-food fortification? A working definition and framework for evaluation of efficiency and implementation of best practices.

Food-to-food fortification (FtFF) is an emerging food-based strategy that can complement current strategies in the ongoing fight against micronutrient deficiencies, but it has not been defined or characterized. This review has proposed a working definition of FtFF. Comparison with other main food-based strategies clearly differentiates FtFF as an emerging strategy with the potential to address multiple micronutrient deficiencies simultaneously, with little dietary change required by consumers. A review of literature revealed that despite the limited number of studies (in vitro and in vivo), the diversity of food-based fortificants investigated and some contradictory data, there are promising fortificants, which have the potential to improve the amount of bioavailable iron, zinc, and provitamin A from starchy staple foods. These fortificants are typically fruits and vegetables, with high mineral as well as ascorbic acid and ß-carotene contents. However, as the observed improvements in micronutrient bioavailability and status are relatively small, measuring the positive outcomes is more likely to be impactful only if the FtFF products are consumed as regular staples. Considering best practices in implementation of FtFF, raw material authentication and ingredient documentation are critical, especially as the contents of target micronutrients and bioavailability modulators as well as the microbiological quality of the plant-based fortificants can vary substantially. Also, as there are only few developed supply chains for plant-based fortificants, procurement of consistent materials may be problematic. This, however, provides the opportunity for value chain development, which can contribute towards the economic growth of communities, or hybrid approaches that leverage traditional premixes to standardize product micronutrient content.

Is It Safe to Fly Patients with Penetrating Trauma in a Rural State?

BACKGROUND: There is limited data pertaining to the triage and transportation of patients with penetrating trauma in rural states. Large urban trauma centers have found rapid transport to be beneficial even when done by nonemergency medical staff. However, there is limited application to a rural state with only a single level 1 trauma center. MATERIALS AND METHODS: This a retrospective observational study of 854 trauma patients transported by helicopter emergency services between 2009 and 2015 to the state's only level 1 trauma center. RESULTS: After excluding patients with other injuries or lack of data, 854 patients underwent final analysis. Compared with penetrating trauma, blunt trauma had a significantly different chance of survival (92.0% versus 81.2%, P = 0.002) and a significantly different injury severity score (17 ± 12 versus 12 ± 9, P = 0.002). After controlling for blunt injuries, age, gender, injury severity score, tachycardia, tachypnea, hypotension, glasgow coma scale, and dispatch to hospital arrival time in multivariate analysis, blunt trauma had higher odds of survival than penetrating trauma (OR, 5.97; 95% CI, 2.52-14.12; P = <0.001 = 1). Gender, tachycardia, tachypnea, and dispatch to arrival time did not impact a patient's likelihood of survival. CONCLUSIONS: Penetrating trauma has a higher mortality when compared with blunt trauma in Helicopter Emergency Services transported patients in a rural state. Perhaps a new algorithm in the management of penetrating trauma would include hemorrhage control at a locoregional hospital before definitive care. Further study is required to understand the exact variables that lead to a higher mortality in penetrating trauma in a rural state.

Improving iron and zinc bioaccessibility through food-to-food fortification of pearl millet with tropical plant foodstuffs (moringa leaf powder, roselle calyces and baobab fruit pulp).

Essential mineral (iron and zinc) deficiencies are still prevalent in the Semi-arid Tropics, where many people consume monotonous, predominantly cereal-based diets. This study aimed to evaluate the potential of including tropical plant foodstuffs high in iron and zinc (moringa leaves and roselle calyces) or mineral availability enhancers (baobab fruit pulp) in a pearl millet-based food containing a plant food-based provitamin A source, with the aim of preventing iron and zinc deficiencies in the Semi-arid Tropics. Mineral bioaccessibility was assessed by dialysability assay. Moringa, roselle and baobab considerably increased iron and zinc bioaccessibility when added at 10 parts:100 parts pearl millet (dry basis). These foodstuffs, increased the contribution to the absolute iron requirements of women of reproductive age by 2.5, 2.1 and 2.3 times for moringa, roselle and baobab, respectively and to their absolute zinc requirements by 2.4, 2.1 and 2.7 times, respectively. Combining these plant foodstuffs could contribute up to 28% and 41% of the women's absolute iron and zinc requirements, respectively, from a single meal. Moringa, despite having the highest iron content, when added at a very high level (30 parts:100 parts pearl millet) decreased bioaccessible iron and zinc, most probably primarily due to its high calcium content. Food-to-food fortification of staple cereal foods with moringa leaves, roselle calyces or baobab fruit pulp plus a provitamin A source can potentially sustainably improve iron and zinc bioavailability in the diets of at-risk communities in the Semi-arid Tropics.

Locust displacing winds in eastern Australia reassessed with observations from an insect monitoring radar.

Based on previous investigations, adult Australian plague locusts are believed to migrate on warm nights (with evening temperatures >25 °C), provided daytime flight is suppressed by surface winds greater than the locusts' flight speed, which has been shown to be 3.1 m s-1. Moreover, adult locusts are believed to undertake briefer 'dispersal' flights on nights with evening temperature >20 °C. To reassess the utility of these conditions for forecasting locust flight, contingency tests were conducted comparing the nights selected on these bases (predicted nights) for the months of November, January, and March and the nights when locust migration were detected with an insect monitoring radar (actual nights) over a 7-year period. In addition, the wind direction distributions and mean wind directions on all predicted nights and actual nights were compared. Observations at around 395 m above ground level (AGL), the height at which radar observations have shown that the greatest number of locusts fly, were used to determine the actual nights. Tests and comparisons were also made for a second height, 990 m AGL, as this was used in the previous investigation. Our analysis shows that the proposed criteria are successful from predicting migratory flight only in March, when the surface temperature is effective as a predicting factor. Surface wind speed has no predicting power. It is suggested that a strong daytime surface wind speed requirement should not be considered and other meteorological variables need to be added to the requirement of a warm surface temperature around dusk for the predictions to have much utility.

Sensitivity of the rate of nutrient uptake by chemotactic bacteria to physical and biological parameters in a turbulent environment.

In this study, we use direct numerical simulations (DNS) to investigate the response of chemotactic bacteria to an isolated patch of chemoattractant in a turbulent environment. Previous work has shown that by stirring nutrients that are chemoattractants into a network of thin, elongated filaments, turbulence directly influences the rate at which chemotactic bacteria consume nutrients. However, the quantitative outcome of this process is influenced by a host of physical and biological factors, and many of these remain unexplored. Here, we analyse the sensitivity of nutrient uptake by chemotactic bacteria on a wide range of physical and biological parameters using a series of controlled DNS. Starting with uniformly distributed populations of motile and non-motile bacteria in a fully developed homogeneous, isotropic turbulent flow, we inject a patch of dissolved nutrients. We then assess the chemotactic advantage, defined as the difference between the nutrients consumed by motile and non-motile bacteria over the lifetime of the patch. We find that the chemotaxis can enhance the total uptake rate by a factor of 1.6 and allows the population of chemotactic bacteria to absorb nutrients 2.2 times faster than non-motile bacteria Results show that chemotactic bacteria are subject to a trade-off between swimming to leave regions devoid of nutrients and, once a nutrient gradient is detected, staying in regions of large nutrient concentration. These findings could help explain how the physical characteristics of turbulent marine ecosystems influence the optimal biological traits of bacteria through the competition for limited resources.

Effect of sorghum type and malting on production of free amino nitrogen in conjunction with exogenous protease enzymes.

BACKGROUND: Sorghum types suitable for brewing and bioethanol production are required. The effect of sorghum type (white non-tannin versus white type II tannin) on free amino nitrogen (FAN) production from sorghum grain and malt using exogenous protease enzymes was investigated over extended incubation at moderate temperature (45 °C). RESULTS: With grain in the absence of exogenous proteases, white non-tannin sorghum produced substantially higher levels of FAN than white type II tannin sorghum, due to the tannins in the latter. Incubating sorghum grain with neutral proteinase and amino-peptidase in combination improved FAN production. The two sorghum types produced similar FAN levels when malted and incubated in the absence of the exogenous proteases. When both sorghums were malted and incubated with neutral proteinase alone substantially more FAN yield (124-126 mg 100 g(-1)) occurred than with grains (61-84 mg 100 g(-1)). The combination of amino-peptidase and proteinase did not improve FAN further. Neither, did malting influence wort free amino acid profile. Group B amino acids constituted the highest percentage (42-47%). CONCLUSION: With grain, white non-tannin sorghum plus proteinase and amino-peptidase yields the highest FAN, with malt both white non-tannin and white type II tannin sorghums plus proteinase yield the highest FAN.

Effects of processing sorghum and millets on their phenolic phytochemicals and the implications of this to the health-enhancing properties of sorghum and millet food and beverage products.

Sorghum and millet grains are generally rich in phytochemicals, particularly various types of phenolics. However, the types and amounts vary greatly between and within species. The food-processing operations applied to these grains, i.e. dehulling and decortication, malting, fermentation and thermal processing, dramatically affect the quantity of phenolics present, most generally reducing them. Thus the levels of phytochemicals in sorghum and millet foods and beverages are usually considerably lower than in the grains. Notwithstanding this, there is considerable evidence that sorghum and millet foods and beverages have important functional and health-promoting effects, specifically antidiabetic, cardiovascular disease and cancer prevention, due to the actions of these phytochemicals. Also their lactic acid bacteria-fermented products may have probiotic effects related to their unique microflora. However, direct proof of these health-enhancing effects is lacking as most studies have been carried out on the grains or grain extracts and not the food and beverage products themselves, and also most research work has been in vitro or ex vivo and not in vivo. To provide the required evidence, better designed studies are needed. The sorghum and millet products should be fully characterised, especially their phytochemical composition. Most importantly, well-controlled human clinical studies and intervention trials are required.

Co-suppression of synthesis of major α-kafirin sub-class together with γ-kafirin-1 and γ-kafirin-2 required for substantially improved protein digestibility in transgenic sorghum.

KEY MESSAGE: Co-suppressing major kafirin sub-classes is fundamental to improved protein digestibility and nutritional value of sorghum. The improvement is linked to an irregularly invaginated phenotype of protein bodies. ABSTRACT: The combined suppression of only two genes, γ kafirin-1 (25 kDa) and γ-kafirin-2 (50 kDa), significantly increases sorghum kafirin in vitro digestibility. Co-suppression of a third gene, α-kafirin A1 (25 kDa), in addition to the two genes increases the digestibility further. The high-digestibility trait has previously only been obtained either through the co-suppression of six kafirin genes (α-A1, 25 kDa; α-B1, 19 kDa; α-B2, 22 kDa; γ-kaf1, 27 kDa; γ-kaf 2, 50 kDa; and δ-kaf 2, 18 kDa) or through random chemical-induced mutations (for example, the high protein digestibility mutant). We present further evidence that suppressing just three of these genes alters kafirin protein cross-linking and protein body microstructure to an irregularly invaginated phenotype. The irregular invaginations are consistent with high pepsin enzyme accessibility and hence high digestibility. The approach we adopted towards increasing sorghum protein digestibility appears to be an effective tool in improving the status of sorghum as a principal supplier of energy and protein in poor communities residing in marginal agro-ecological zones of Africa.

Effects of aqueous soaking on the phytate and mineral contents and phytate:mineral ratios of wholegrain normal sorghum and maize and low phytate sorghum.

Soaking of cereal grains has been suggested as a method to reduce their phytate content and hence increase their mineral availability. Whole and milled wholegrain, normal and low phytate sorghum and normal maize were studied. Soaking of unmilled sorghum and maize did not result in substantial reductions in phytate or mineral contents. With milled grains, phytate solubilisation was somewhat greater in maize than in sorghum after a short (1 h) soaking period but not after 6-12 h of soaking when practically all phytate had been solubilised. Also, with milled, low phyate sorghums, phytate solubilisation was not substantially higher than in their null controls. Soaking milled grain substantially reduced mineral contents and Ca × phytate:zinc molar ratios. However, the loss in soluble minerals could have a greater negative effect on mineral availability, compared to the positive effect of the phytate reduction. Thus, soaking does not seem to be a viable household method to improve sorghum and maize mineral availability.

A profile of urban agricultural growers, organizations, their needs, and challenges in the Northeastern United States.

Urban agriculture is increasingly valued as a strategy for improving quality of life in cities, but urban growers face challenges and often lack coordinated support from governments and the agricultural industry. We surveyed urban growers through an online survey, primarily in the Northeastern United States, to develop a profile of growers and associated organizations, assess the current state of urban agriculture, and determine how universities could help meet their needs. A total of 394 respondents completed the survey and most urban growers were white (non-Hispanic) and younger than 45 years old. Women and men were in almost equal proportion. Urban growers were well-educated, but most did not receive a degree in agriculture. Urban agriculture in our study area was dominated by relatively small non-profit organizations and home and community gardens were the most common types of organizations. Urban agricultural organizations want to improve environmental sustainability and socio-cultural conditions through food access and security, regardless of their tax status. Urban growers face diverse barriers and challenges and the most ubiquitous barriers and challenges reported by respondents were related to availability of land and long-term access in urban areas. Many respondents received low revenue or were operating at a net loss even though they reported diverse income streams. Respondents need a wide range of training, including in traditional agricultural topics as well as financial management and business trainings. Universities can play a key role in promoting urban agriculture by offering training and research. Workforce development is a large priority among universities, so urban growers should regularly be consulted, and the results shared with career and workforce development professionals and researchers in urban areas to identify training and research that meets the needs of stakeholders.

Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls soccer coaches.

Women are 3 times more likely to injure their anterior cruciate ligament (ACL) while playing soccer than men. ACL injury prevention programs (IPPs) involving stretching and strengthening drills can reduce the incidence of ACL injury when incorporated into routine training. The rate of implementation among coaches is largely unknown. The purpose of this study was to determine the rate of implementation of ACL IPP, to identify factors that influence implementation, and to acquire information to assist in design dissemination and implementation strategies. Study subjects were coaches of woman soccer players aged 11-22 years in Utah (n = 756). Data were gathered using a Web-based survey followed by a qualitative study in which "best practice coaches"-coaches who met criteria for successful implementation of ACL IPP-were interviewed via telephone. A minority of survey respondents, 19.8% (27/136), have implemented ACL IPP. Factors associated with successful implementation include length of coaching experience and presence of additional support staff such as a strength and conditioning coach or athletic trainer. Best practice coaches (14/136) unanimously agreed on the following: (a) there are performance-enhancing benefits of ACL IPP, (b) education on ACL injury prevention should be required for licensure, and (c) dissemination and implementation will require soccer associations to enact policies that require IPPs. In conclusion, a minority of girls soccer coaches have implemented ACL IPP and those that have do so because they believe that prevention improves performance and that soccer organizations should enact policies requiring ACL injury prevention education and implementation. Efforts to implement ACL IPP should be driven by soccer organizations, emphasize performance-enhancing benefits, and engage additional coaching staff.

New musical interfaces for older adults in residential care: assessing a user-centred design approach.

Purpose:For older adults in aged-care, group music-making can bring numerous physical and psychological benefits, ultimately improving their quality of life. However, personalising music-making to optimise these benefits is often difficult given their diverse ages, experiences, abilities, cognitive and motor skills, and their experience with music technology.Materialsandmethods:In this study, we conducted a 10-week group music-making intervention with twenty participants in an aged-care home, using a prototype digital musical instrument that we iteratively refined by following a user-centred design approach from direct resident feedback. The prototype instrument adopted a novel method for errorless learning in music-making settings, which we also refined, by increasing the difficulty level of the instrument's operation. We also assessed the residents' engagement with the sessions by obtaining feedback from caregivers and facilitators.Results:Results show that residents' enjoyment decreased as the complexity (difficulty) of our errorless learning implementation increased. We also found that resident engagement increased when changes to the prototype digital musical instrument were provided, but not when residents were giving feedback. Results also found that participation over the course of the intervention, and the number of songs played during each session also enhanced engagement.Conclusions: Overall, our results show the intervention was beneficial to residents, although we note some areas of enhancement for further interventions in designing prototype musical instruments for group music-making in aged-care settings. IMPLICATIONS FOR REHABILITATIONOlder adults positively engage with novel music technology, and do so increasingly over subsequent sessions. Repeated sessions may have the potential to enhance longer-term adoption of technologies as well as any rehabilitative effects of the group music-making activity.There is significant potential for residents with different abilities to all make music together, although to maximise the sustainability of the devices, the sessions, and the subsequent rehabilitative benefits, residents must be given the right adaptation for individual interfaces that balances ambition and ability.Rapid DMI prototyping positively enhances engagement among older adults, suggesting that in the case of a custom DMI, an upgrade schedule should be aligned with key rehabilitative milestones. Similarly, in the case of pre-developed digital music systems, resident exposure to new features or functionality should be strategically introduced, so as to maximise engagement for key phases of resident rehabilitation.

Beyond burnout: a four-year survey of osteopathic medical student mental health and the implications for the development of wellness and mental health programs.

CONTEXT: The mental health crisis in medicine cannot be explained by burnout alone. Physicians are not immune to this crisis and are known to have higher rates of suicide and depression than the general population. A high prevalence of mental health symptoms has been observed in early medical training. OBJECTIVES: This study was completed to characterize medical students' mental well-being and provide guidance for timely intervention. METHODS: An annual prospective, voluntary, anonymous, cross-sectional survey of medical students was completed over a 4-year period in medical school from 2016 to 2019. The survey was created based on standardized psychiatric screening tools assessing symptoms of depression, anxiety, burnout, and sleep problems. In each of those years, 1,257 (2016), 1,254 (2017), 1,221 (2018), and 1,220 (2019) enrolled students, respectively, were invited to participate. Data on students' mental health were analyzed in relation to their year of school separately for each survey year utilizing SAS 9.4. RESULTS: A total of 973 students in 2016, 889 students in 2017, 547 students in 2018, and 606 students in 2019 participated in the study. For depression and burnout subscales, an increase in symptom scores were observed every survey year (2016, 2017, 2018, and 2019) by the second or third year of medical school with a clinically significant effect size. Persistently high levels of anxiety were observed throughout medical school, with significant increases after the first year noted in the 2016 and 2017 surveys, but not in the 2018 or 2019 surveys. Similarly, significant changes in sleep disturbance were found in the 2016 and 2017 surveys, but not in 2018 or 2019. CONCLUSIONS: Symptoms of burnout, depression, and anxiety were observed throughout all four years of medical school, with increases starting after the first year. Early intervention is needed to support students' mental health and increase access to care and resources.