Impact of physical exercise on sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system in people with Type 1 diabetes: a randomized crossover trial.

AIMS: To evaluate the sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system using reference blood glucose levels during moderate-intensity exercise while on either full or reduced basal insulin dose in people with Type 1 diabetes. METHODS: Ten participants with Type 1 diabetes [four women, mean ± sd age 31.4 ± 9.0 years, BMI 25.5±3.8 kg/m2 , HbA1c 55±7 mmol/mol (7.2±0.6%)] exercised on a cycle ergometer for 55 min at a moderate intensity for 5 consecutive days at the clinical research facility, while receiving either their usual or a 75% basal insulin dose. After a 4-week washout period, participants performed the second exercise period having switched to the alternative basal insulin dose. During exercise, reference capillary blood glucose values were analysed using the fully enzymatic-amperometric method and compared with the interstitial glucose values obtained. Intermittently viewed continuous glucose monitoring accuracy was analysed according to median (interquartile range) absolute relative difference, and Clarke error grid and Bland-Altman analysis for overall glucose levels during exercise, stratified by glycaemic range and basal insulin dosing scheme (P<0.05). RESULTS: A total of 845 glucose values were available during exercise to evaluate intermittently viewed continuous glucose monitoring sensor performance. The median (interquartile range) absolute relative difference between the reference values and those obtained by the sensor across the glycaemic range overall was 22 (13.9-29.7)%, and was 36.3 (24.2-45.2)% during hypoglycaemia, 22.8 (14.6-30.6)% during euglycaemia and 15.4 (9-21)% during hyperglycaemia. Usual basal insulin dose was associated with a worse sensor performance during exercise compared with the reduced (75%) basal insulin dose [median (interquartile range) absolute relative difference: 23.7 (17.2-30.7)% vs 20.5 (12-28.1)%; P<0.001). CONCLUSIONS: The intermittently viewed continuous glucose monitoring sensor showed diminished accuracy during exercise. Absolute glucose readings derived from the sensor should be used cautiously and need confirmation by additional finger-prick blood glucose measurements.

Pushing the limits of in vivo diffusion MRI for the Human Connectome Project.

Perhaps more than any other "-omics" endeavor, the accuracy and level of detail obtained from mapping the major connection pathways in the living human brain with diffusion MRI depend on the capabilities of the imaging technology used. The current tools are remarkable; allowing the formation of an "image" of the water diffusion probability distribution in regions of complex crossing fibers at each of half a million voxels in the brain. Nonetheless our ability to map the connection pathways is limited by the image sensitivity and resolution, and also the contrast and resolution in encoding of the diffusion probability distribution. The goal of our Human Connectome Project (HCP) is to address these limiting factors by re-engineering the scanner from the ground up to optimize the high b-value, high angular resolution diffusion imaging needed for sensitive and accurate mapping of the brain's structural connections. Our efforts were directed based on the relative contributions of each scanner component. The gradient subsection was a major focus since gradient amplitude is central to determining the diffusion contrast, the amount of T2 signal loss, and the blurring of the water PDF over the course of the diffusion time. By implementing a novel 4-port drive geometry and optimizing size and linearity for the brain, we demonstrate a whole-body sized scanner with G(max) = 300 mT/m on each axis capable of the sustained duty cycle needed for diffusion imaging. The system is capable of slewing the gradient at a rate of 200 T/m/s as needed for the EPI image encoding. In order to enhance the efficiency of the diffusion sequence we implemented a FOV shifting approach to Simultaneous MultiSlice (SMS) EPI capable of unaliasing 3 slices excited simultaneously with a modest g-factor penalty allowing us to diffusion encode whole brain volumes with low TR and TE. Finally we combine the multi-slice approach with a compressive sampling reconstruction to sufficiently undersample q-space to achieve a DSI scan in less than 5 min. To augment this accelerated imaging approach we developed a 64-channel, tight-fitting brain array coil and show its performance benefit compared to a commercial 32-channel coil at all locations in the brain for these accelerated acquisitions. The technical challenges of developing the over-all system are discussed as well as results from SNR comparisons, ODF metrics and fiber tracking comparisons. The ultra-high gradients yielded substantial and immediate gains in the sensitivity through reduction of TE and improved signal detection and increased efficiency of the DSI or HARDI acquisition, accuracy and resolution of diffusion tractography, as defined by identification of known structure and fiber crossing.

Ion thrusters for electric propulsion: Scientific issues developing a niche technology into a game changer.

The transition from old space to new space along with increasing commercialization has a major impact on space flight, in general, and on electric propulsion (EP) by ion thrusters, in particular. Ion thrusters are nowadays used as primary propulsion systems in space. This article describes how these changes related to new space affect various aspects that are important for the development of EP systems. Starting with a historical overview of the development of space flight and of the technology of EP systems, a number of important missions with EP and the underlying technologies are presented. The focus of our discussion is the technology of the radio frequency ion thruster as a prominent member of the gridded ion engine family. Based on this discussion, we give an overview of important research topics such as the search for alternative propellants, the development of reliable neutralizer concepts based on novel insert materials, as well as promising neutralizer-free propulsion concepts. In addition, aspects of thruster modeling and requirements for test facilities are discussed. Furthermore, we address aspects of space electronics with regard to the development of highly efficient electronic components as well as aspects of electromagnetic compatibility and radiation hardness. This article concludes with a presentation of the interaction of EP systems with the spacecraft.

Number and cost of hospitalizations with principal and secondary diagnoses of tuberculosis, United States.

OBJECTIVE: To estimate the number and cost of hospitalizations with a diagnosis of active tuberculosis (TB) disease in the United States. METHODS: We analyzed the 2014 National In-Patient Sample using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes to identify hospitalizations with a principal (TB-PD) or any secondary discharge (TB-SD) TB diagnosis. We used a generalized linear model with log link and gamma distribution to estimate the cost per TB-PD and TB-SD episode adjusted for patient demographics, insurer, clinical elements, and hospital characteristics. RESULTS: We estimated 4985 TB-PD and 6080 TB-SD hospitalizations nationwide. TB-PD adjusted averaged $16 695 per episode (95%CI $16 168-$17 221). The average for miliary/disseminated TB ($22 498, 95%CI $21 067-$23 929) or TB of the central nervous system ($28 338, 95%CI $25 836-$30 840) was significantly greater than for pulmonary TB ($14 819, 95%CI $14 284-$15 354). The most common principal diagnoses for TB-SD were septicemia (n = 965 hospitalizations), human immunodeficiency virus infection (n = 610), pneumonia (n = 565), and chronic obstructive pulmonary disease and bronchiectasis (COPD-B, n = 150). The adjusted average cost per TB-SD episode was $15 909 (95%CI $15 337-$16 481), varying between $8687 (95%CI $8337-$9036) for COPD-B and $23 335 (95%CI $21 979-$24 690) for septicemia. TB-PD cost the US health care system $123.4 million (95%CI $106.3-$140.5) and TB-SD cost $141.9 million ($128.4-$155.5), of which Medicaid/Medicare covered respectively 67.2% and 69.7%. CONCLUSIONS: TB hospitalizations result in substantial costs within the US health care system.

Maternal obesity and risk of cesarean delivery: a meta-analysis.

Despite numerous studies reporting an increased risk of cesarean delivery among overweight or obese compared with normal weight women, the magnitude of the association remains uncertain. Therefore, we conducted a meta-analysis of the current literature to provide a quantitative estimate of this association. We identified studies from three sources: (i) a PubMed search of relevant articles published between January 1980 and September 2005; (ii) reference lists of publications selected from the search; and (iii) reference lists of review articles published between 2000 and 2005. We included cohort designed studies that reported obesity measures reflecting pregnancy body mass, had a normal weight comparison group, and presented data allowing a quantitative measurement of risk. We used a Bayesian random effects model to perform the meta-analysis and meta-regression. Thirty-three studies were included. The unadjusted odd ratios of a cesarean delivery were 1.46 [95% confidence interval (CI): 1.34-1.60], 2.05 (95% CI: 1.86-2.27) and 2.89 (95% CI: 2.28-3.79) among overweight, obese and severely obese women, respectively, compared with normal weight pregnant women. The meta-regression found no evidence that these estimates were affected by selected study characteristics. Our findings provide a quantitative estimate of the risk of cesarean delivery associated with high maternal body mass.

Phenotypic characterization of paranoiac and related mutants in Paramecium tetraurelia.

Paranoiac and related mutants of Paramecium tetraurelia display altered membrane excitability. We describe an extension of behavioral characterizations of the paranoiac, fast-2, and tetraethylammonium-insensitive mutants, comparing in detail their reactions to sodium stimulation under standard culture conditions, when grown at various temperatures and when starved. We also use freeze-fracture electron microscopic techniques to analyze in these stocks the morphology of organized arrays of membrane particles, the ciliary plaques. This group of mutants is diverse, showing differences in behavior under standard culture conditions and different reactions to temperature and starvation stresses. Ciliary plaque morphology is altered in some, but not all, of the mutants. The possibility is discussed that these plaques may be sites of potassium or sodium transport.

Mentally disordered offenders who push or attempt to push victims onto subway tracks in New York City.

Violent offenders who pushed or attempted to push victims onto the subway tracks in New York City during the 17-year period from 1975 through 1991 were studied. Forty-nine incidents involving 52 victims were identified during this period. Of 36 perpetrators who acted alone, 25 (69%) were referred for psychiatric evaluation and treatment, as was one member of an offending gang. Data concerning 20 of these 26 offenders and their crimes were collected. At the time of the offense, 19 (95%) of these offenders were psychotic, and 13 (65%) were homeless. Most of these offenders had extensive histories of psychiatric hospitalization and several prior arrests and convictions, often for violent crimes. The offenders had extensive mental health and criminal histories. The victims of these crimes were always strangers. Half of the offenders killed or seriously injured victims. Since 1986, the incidence of this offense has increased, and offenders accounting for the increase are mostly psychotic and homeless.

Battery incidents and batterers in a maximum security hospital.

Of 638 reported assaultive and disruptive incidents in 1979 in a maximum security hospital, 221 (34.6%) were batteries. Whether an incident was a battery or not was a function of time and location. Preludes to battery were noted by staff in only 23.1% of cases and were high-frequency behaviors with low predictive value. Impact and injury to patients and officers occurred through both batteries themselves and efforts to subdue the batterer. With length of hospitalization controlled, the distributions of preadmission criminal charges were not significantly different between batterers and controls. Policies that alter patterns in the timing and location of interaction among patients and in the response of officers or other personnel to batteries in progress offer promise for reducing incident and injury rates.

Social discrediting of psychiatry: the protasis of legal disfranchisement.

The author believes that recent legal decisions against psychiatrists (including class action suits) have their genesis in writings by sociologists and other behavioral scientists, including psychiatrists, who have examined psychiatry in the context of social structure and social processes. The discrediting of the medical model could have been accomplished using theorectical assertions and research observations that had been published before 1940, but it did not occur until the human rights movement of the 1960s. The author reviews the assertions on which the discrediting of the medical model has been based. He stresses the distinction between the testing of a theory and the discrediting of a model and observes that the recent wholesale discrediting of psychiatry has relied less on theory testing than on polemical rhetoric and unwarranted extrapolation from empirical facts.

Pornographic imagery and prevalence of paraphilia.

The authors classified 1,760 heterosexual pornographic magazines according to the imagery of the cover photographs. Covers depicting only a woman posed alone predominated in 1970 but constituted only 10.7% of the covers in 1981. Bondage and domination imagery was the most prevalent nonormative imagery and was featured in 17.2% of the magazines. Smaller proportions of material were devoted to group sexual activity (9.8%), tranvestism and transsexualism (4.4%), and other nonnormative imagery. The authors suggest that pornographic imagery is an unobtrusive measure of the relative prevalence of those paraphilias associated with preferences for specific types of visual imagery and for which better data are lacking.

Delayed entry into prenatal care: effect of physical violence.

OBJECTIVE: To assess whether women who experienced physical violence by their partner during the 12 months before delivery were more likely to delay entry into prenatal care than were women who had not experienced physical violence. METHODS: We analyzed data from the Pregnancy Risk Assessment Monitoring System. The sample included 27,836 women who delivered live infants during 1993-1994 in nine states and were surveyed 2-6 months after delivery. We calculated risk ratios and 95% confidence intervals (CIs) to measure the association between physical violence within the 12 months before delivery and entry into prenatal care. RESULTS: The prevalence of delayed entry into prenatal care (entering after the first trimester) was 18.1% and that of reported physical violence was 4.7%. Overall, women who experienced physical violence were 1.8 times more likely (95% CI 1.5, 2.1) to have delayed entry into prenatal care than women who had not experienced such violence. When stratifying by selected maternal characteristics, this association was found only for groups of women who were 25 years of age or older or were of higher socioeconomic status. CONCLUSION: Older women and women of higher socioeconomic status who reported physical violence were more likely to delay entry into prenatal care than younger or less affluent women.

Trauma experience of a rural hospital.

We sought to evaluate the ability of a small rural hospital with level 2 trauma capability to provide adequate care to the patient with multiple trauma. Using the TRISS method, we reviewed 163 patients with trauma admitted to our institution over 2 years. An outcome equivalent to those level 1 centers that contributed to the Major Trauma Outcome Study is documented. The clinical commitment and institutional resources necessary are discussed.

Mentally disordered offenders. Patterns in the relationship between mental disorder and crime.

Five patterns among mentally disordered offenders are distinguished by the relationship between mental disorder, on the one hand, and criminality, on the other. Pattern 1 offenders are those for whom crime is a response to psychotic symptoms, most often delusions or hallucinations. Pattern 2 offenders commit crimes motivated by compulsive desires, such as sex offenses by paraphiles and offenses regarded as evidence of disorders of impulse control. Pattern 3 offenders are those with personality disorder for whom the crime is merely one example of a maladaptive pattern of voluntary and knowing behavior. Pattern 4 offenders have coincidental mental illness that is unrelated to the crime. Pattern 5 offenders are those who become mentally disordered or feign mental disorder as a result of their crimes, such as those who dissociate upon seeing what they have done, those who become depressed in prison, those who become psychotic on death row, and those who malinger mental illness. Although these categories do not determine whether offenders are responsible for their behavior, some unknown proportion of Pattern 1 offenders do meet legal criteria for insanity, depending on the facts of each case and the applicable legal standards. It is arguable whether or not Pattern 2 offenders ever meet legal criteria of insanity. Offenders evidencing only Patterns 3, 4, or 5 are not candidates for an insanity defense.

Outcomes of weight-based heparin dosing based on literature guidelines and institution individualization.

STUDY OBJECTIVE: To determine whether unfractionated heparin is optimally dosed using published weight-based guidelines. DESIGN: Six-month, prospective study. SETTING: University hospital. PATIENTS: Ninety-six patients in the weight-based unfractionated heparin-dosing group 1 (WBHD1; 37 men; mean age 66.9 +/- 15.1 years; mean weight 80.1 +/- 20.6 kg) and 68 patients in the WBHD2 (25 men; mean age 68.2 +/- 15.6 years; mean weight 82.0 +/- 19.6 kg). INTERVENTIONS: The WBHD1 received a 100-U/kg intravenous bolus followed by an 18-U/kg/hour continuous intravenous infusion. After 3 months, the protocol was modified, and the WBHD2 received a 90-U/kg bolus followed by a 16-U/kg/hour continuous infusion for 3 months. MEASUREMENTS AND MAIN RESULTS: Activated partial thromboplastin times (aPTTs), frequency of bleeding episodes that required blood transfusions, and the number of recurrent thromboembolic events were collected from both groups after 3 months on the study. In the WBHD1, 24 hours after starting heparin, 38.5% of patients had therapeutic aPTTs, and at 48 hours, 54.3% were therapeutic. In the WBHD2, 42.6% and 51.4% of patients had therapeutic aPTTs at 24 and 48 hours, respectively. There was no statistical difference between the WBHD1 and WBHD2 in the percentage of patients with therapeutic aPTTs. CONCLUSIONS: Weight-based heparin dosing resulted in low percentages of patients with therapeutic aPTTs. The use of weight alone to dose heparin may not be adequate to optimize therapy.

Postmortem plasma luteinizing hormone levels and antemortem violence.

Luteinizing hormone (LH) levels were determined in postmortem blood samples obtained from twenty-eight men who sustained sudden traumatic deaths. Violent antemortem behavior (committing suicide by gunshot or hanging, or killed during a violent attack or physical struggle) was associated with significantly higher LH levels than nonviolent antemortem behavior (pedestrians struck by vehicles, crime victims, and those shot during verbal arguments). Within both the violent and nonviolent groups, LH levels were higher in men with detectable alcohol in blood than in men with no alcohol in blood but these differences were not statistically significant. In the nonviolent group, men without alcohol in blood had LH levels within the normal range for healthy adult males. The stability of LH was established in serial studies of normal human male blood specimens over a range of temperatures and time durations comparable to conditions in postmortem blood sampling procedures. These findings suggest that postmortem LH levels in males may be a biological indicator of violent behavior immediately preceding death.

Investigation of dialysis membranes with atomic force microscopy.

AFM was used to investigate dialysis membranes made of regenerated cellulose by the cuoxam process. The membranes were either Cuprophan or experimental samples, modified with different amounts of diethylaminoethylcellulose (DEAE). Atomic force microscopes with optical-lever detection systems were used to image the dry membranes in air as received from the manufacturer as well as wet membranes in a swollen state under water. Differences could be observed between modified and unmodified as well as between dry and wet membranes.

Dangerous information: product tampering and poisoning advice in revenge and murder manuals.

This paper reviews 18 publications that advocate the use of product tampering and other poisoning methods as techniques for exacting revenge against individuals and corporations, as methods of committing murder, and for other criminal purposes. Several of the particular techniques recommended in these publications subsequently have been used in criminal tampering incidents. The published sources of technical guidance for the would-be tamperer and poisoner are examined in detail to alert forensic scientists, law enforcement authorities, and the food and drug industry to the particular techniques that are being advocated. Possible criminal and civil liability of the publishers and authors is discussed. The author suggests that food and drug retailers consider the wisdom of selling magazines that advertise the availability of revenge and murder manuals advocating product tampering and poisoning, that food and drug manufacturers test the effects on their products of the contaminants that are being recommended, and that investigators be alert to the existence of such manuals and mail-order suppliers of poisons.

Quality of life for the mentally disabled.

Case illustrations are given to suggest the complexity of the effects on the quality of life of developments in psychotropic medicines, deinstitutionalization, and patients' rights. Community services often do not provide the mentally disabled with the benefits predicted for such programs. Whether the net effect of the revolutionary extrusion of the mentally disabled from public hospitals will be beneficial remains for history to judge.

Autoerotic fatalities with power hydraulics.

We report two cases in which men used the hydraulic shovels on tractors to suspend themselves for masochistic sexual stimulation. One man developed a romantic attachment to a tractor, even giving it a name and writing poetry in its honor. He died accidentally while intentionally asphyxiating himself through suspension by the neck, leaving clues that he enjoyed perceptual distortions during asphyxiation. The other man engaged in sexual bondage and transvestic fetishism, but did not purposely asphyxiate himself. He died when accidentally pinned to the ground under a shovel after intentionally suspending himself by the ankles. We compare these cases with other autoerotic fatalities involving perceptual distortion, cross-dressing, machinery, and postural asphyxiation by chest compression.