Impact of Rank, Provider Specialty, and Unit Sustainment Training Frequency on Military Critical Care Air Transport Team Readiness.

BACKGROUND: The Critical Care Air Transport (CCAT) Advanced Course utilizes fully immersive high-fidelity simulations to assess personnel readiness for deployment. This study aims to determine whether simple well-defined demographic identifiers can be used to predict CCAT students' performance at CCAT Advanced. MATERIALS AND METHODS: CCAT Advanced student survey data and course status (pass/fail) between March 2006 and April 2020 were analyzed. The data included students' Air Force Specialty Code (AFSC), military status (active duty and reserve/guard), CCAT deployment experience (yes/no), prior CCAT Advanced training (yes/no), medical specialty, rank, and unit sustainment training frequency (never, frequency less often than monthly, and frequency at least monthly). Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCAT Advanced course for each provider type. RESULTS: A total of 2,576 student surveys were analyzed: 694 (27%) physicians (MDs), 1,051 (40%) registered nurses (RNs), and 842 (33%) respiratory therapists (RTs). The overall passing rates were 92.2%, 90.3%, and 85.4% for the MDs, RNs, and RTs, respectively. The students were composed of 579 (22.5%) reserve/guard personnel, 636 (24.7%) with CCAT deployment experience, and 616 (23.9%) with prior CCAT Advanced training. Regression analysis identified groups with lower odds of passing; these included (1) RNs who promoted from Captain to Major (post-hoc analysis, P = .03), (2) RTs with rank Senior Airman, as compared to Master Sergeants (post-hoc analysis, P = .04), and (3) MDs with a nontraditional AFSC (P = .0004). Predictors of passing included MDs and RNs with CCAT deployment experience, odds ratio 2.97 (P = .02) and 2.65 (P = .002), respectively; and RTs who engaged in unit CCAT sustainment at least monthly (P = .02). The identifiers prior CCAT Advanced training or reserve/guard military status did not confer a passing advantage. CONCLUSION: Our main result is that simple readily available metrics available to unit commanders can identify those members at risk for poor performance at CCAT Advanced readiness training; these include RNs with rank Major or above, RTs with rank Senior Airman, and RTs who engage in unit sustainment training less often than monthly. Finally, MD specialties which are nontraditional for CCAT have significantly lower CCAT Advanced passing rates, reserve/guard students did not outperform active duty students, there was no difference in the performance between different RN specialties, and for MD and RN students' previous deployment experience was a strong predictor of passing.

An automated content-based measure of closed loop communication among critical care air transport teams.

Successful teamwork is essential to ensure critical care air transport (CCAT) patients receive effective care. Despite the importance of team performance, current training methods rely on subjective performance assessments and do not evaluate performance at the team level. Researchers have developed the Team Dynamics Measurement System (TDMS) to provide real-time, objective measures of team coordination to assist trainers in providing CCAT aircrew with feedback to improve performance. The first iteration of TDMS relied exclusively on communication flow patterns (i.e., who was speaking and when) to identify instances of various communication types such as closed loop communication (CLC). The research presented in this paper significantly advances the TDMS project by incorporating natural language processing (NLP) to identify CLC. The addition of NLP to the existing TDMS resulted in greater accuracy and fewer false alarms in identifying instances of CLC compared to the previous flow-based implementation. We discuss ways in which these improvements will facilitate instructor feedback and support further refinement of the TDMS.

Links between socio-demographic characteristics and body mass index to colorectal cancer in North Borneo, Malaysia: A case-control study.

INTRODUCTION: The fourth leading cause of cancer-related mortality and morbidity worldwide is colorectal cancer (CRC). Numerous reasons have contributed to the massive rise in CRC cases, for which Asian nations differ significantly in terms of risk incidence rates. The objectives of this study were to, first, identify the socio-demographic characteristics of those of North Borneo ethnicity and body mass index (BMI) and, second, determine the association of these factors with CRC. This research will contribute to preventing this form of cancer. MATERIALS AND METHODS: This study is an analysis of a matched case-control study with a ratio of 1:2. The case group contained 206 respondents, and the control group contained 412. All CRC cases were confirmed with the histological results. The control group was matched for links between age, sex and ethnicity with CRC. The Statistical Package for Social Sciences Statistics (SPSS) IBM version 28.0 was used to conduct descriptive analysis using chi-squared testing and simple logistic regression. The statistical significance was P < 0.05. RESULT: Overall, 618 respondents took part in this survey, of which 256 (41.4%) were female and 362 (58.6%) were male. The maximum age was 76, with a mean age ± SD of 53.17 ± 11.4. Those of Bajau ethnicity comprised 24.6% (152) of the population, followed by Dusun with 22.8% (141), Kadazan with 17.6% (109%), other North Borneo ethnic groups with 15.5% (96), Bugis with 9.7% (60), Brunei with 4.4% (27) and other predominant races with 5.3% (33). Regression analyses revealed that the incidence of CRC in North Borneo, Malaysia, was substantially correlated with income, occupation, other linked diseases and BMI. CONCLUSION: Various risk factors are linked to CRC, based on the findings related to socio-demographic characteristics and BMI. Therefore, to lower the nationwide prevalence of CRC, national public health campaigns should include collaboration with the regional authorities to highlight the incidence and risk factors of CRC based on ethnicity.

Mindfulness-based therapy for smoking cessation and mental health: a randomised controlled trial.

INTRODUCTION: Effective smoking cessation programmes are essential for assisting smokers in quitting, indirectly lowering mortality and morbidity associated with smoking. Numerous studies have indicated positive outcomes when using mindfulness treatment (MT) to treat psychological or behavioural health issues. Although to date, no study has looked at the effectiveness of online MT for quitting smoking while addressing mental health, particularly among the Asian population. Therefore, this study compares the efficiency of online MT to traditional counselling therapy (CT) in aiding smoking cessation programmes while also addressing mental health. MATERIALS AND METHODS: A randomised control study with a two-group, single-blind design and baseline evaluation was selected. Social media sites were used to advertise for participants, who were then admitted after meeting the requirements. Participants who met the eligibility requirements were randomly split into two groups. Each group received a total of three sessions of online therapy (MT or CT), once every two weeks, as well as one phone call per week as reinforcement. At the beginning and end of the intervention, participants completed questionnaires (1st week and 5th week). Generalized Estimating Equation (GEE) statistical analysis was used to analyse all the variables. RESULTS: The MT group experienced a statistically significant decrease in cigarette consumption (ß: -3.50, 95% Wald CI: - 4.62, -2.39) compared to the CT group over time. Furthermore, the MT group demonstrated significant improvements in their scores for the AAQ-2, anxiety, stress, depression and mindfulness compared to the CT group. CONCLUSION: Online MT is more successful at assisting smokers in lowering their daily cigarette intake and supporting their mental health during the smoking cessation process. Further longitudinal comparisons of the effectiveness of online MT should be undertaken using online platforms in future studies.

Team Coordination Style Is an Adaptive, Emergent Property of Interactions Between Critical Care Air Transport Team Personnel.

OBJECTIVE: Critical Care Air Transport (CCAT) teams care for critically ill or injured patients during long-duration flights. Despite the differences between the CCAT domain and a more traditional clinical setting, CCAT clinicians are not explicitly trained how to coordinate care in the aircraft environment. We characterized the team coordination patterns adopted by CCAT teams and explored any links between team coordination style and performance. METHODS: This retrospective study used transcripts from 91 CCAT teams as they completed simulated patient care scenarios during an advanced training course. Qualitative and quantitative measures were used to characterize team behavior. RESULTS: Vocalized content varied by team role, with physicians acting as leaders. The type of content verbalized by each team role depended on the team coordination style. The team coordination style and the content of vocalized messages were not affected by prior team member deployment or the characteristics of particular scenarios, and the team coordination style did not predict measures related to patient status. CONCLUSION: Individual team member coordination behaviors vary depending on the coordination style used by the team as a whole. Coordination style appears to arise from the interactions among individual team members rather than in response to situational factors external to the team.

Descriptive Analysis of Intratheater Critical Care Air Transport Team Patient Movements During Troop Drawdown: Afghanistan (2017-2019).

BACKGROUND: The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe. STUDY DESIGN: We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age. RESULTS: We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02). CONCLUSION: During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training.

Components of aircraft life support systems interact with each other and the user.

The life support system in a tactical aircraft provides necessary supplemental oxygen to the aircrew. However, interactions among its various components may generate unexpected breathing loads. We focus here on the interactions between a regulator and breathing mask commonly used together in the U.S. Navy, the CRU-103 regulator and MBU 23/P mask, and some effects of the interactions on the user. The data reported were collected during a larger research effort examining potential physiological and cognitive effects of low regulator inlet pressures. Seventeen participants completed a series of tasks under mild exercise while breathing 40% O2 (balance N2) from an MBU-23/P mask supplied by a CRU-103 regulator with supply pressures 10, 6, 4, and 2 psig (CRU-103 specifications are for inlet pressures from 5 to 120 psig). Variables measured included flow to the mask and pressures at the regulator supply, in the hose to the mask, and in the mask. In addition to restricting inspiratory flow, low inlet pressure to the CRU-103 caused a counterintuitive overshoot in gas delivery pressure at end-inspiration, a mean increase of 1.5 cm H2O between the 10- and 2 psig conditions. The added pressure to the exhalation valve increased the expiratory threshold, the pressure to start expiratory flow, by approximately 2 cm H2O, increasing the effort needed to exhale.

Evolution of maternal feed restriction practices over 60 years of selection for broiler productivity.

The effect of commercial selection by poultry breeders on the growth, efficiency, and sexual maturity of broiler breeders was studied using 2 University of Alberta Meat Control strains unselected since 1957 and 1978 (AMC-1957 and AMC-1978, respectively) and 2 strains originating from the University of Arkansas; 1995 Random-bred (1995RB) and 2015 Random-bred (2015RB). A study with a 4 × 2 factorial arrangement was conducted with the 4 strains fed at either ad libitum, or restricted levels to achieve a current commercial breeder target BW profile. Growth rate, feed intake, feed efficiency, age at sexual maturity, carcass components, and body conformation were measured. To assess reproductive development, birds were assigned to 2 fates: dissected at photostimulation or dissected after the second oviposition. At 22.4 wk of age, the restricted-fed AMC-1957, AMC-1978, 1995RB, and 2015RB reached 100, 61, 46, and 38% of their ad libitum-fed counterparts' BW, respectively. During the rearing phase, the amount of feed needed to maintain restricted-fed birds on the target BW was 99.4, 57, 29.5, and 24.9% of their ad libitum-fed counterparts for AMC-1957, AMC-1978, 1995RB, and 2015RB, respectively. Feed restricted birds in the 2015RB had lower heat production relative to the AMC-1957 and AMC-1978, which shows that modern strains utilized feed more efficiently compared to the antique strains. This might be related to the increasing severity of feed restriction of broiler breeders over the past 60 years. Relative to AMC-1957 and AMC-1978 strains, the 1995RB and 2015RB strains had heavier breast muscle and lower fat pad weight. Although the pubertal threshold for age and BW have increased over the last 6 decades, changes in selection programs for feed efficiency have resulted in broiler breeders that prioritize nutrient allocation to growth and breast development rather than adipose storage. As a result, feed restricted modern broiler breeders may have marginally sufficient fat resources to support reproduction.

Relevance of Deployment Experience and Clinical Practice Characteristics on Military Critical Care Air Transport Team Readiness: A Study of Simulation Construct Validity.

INTRODUCTION: The Critical Care Air Transport Team (CCATT) Advanced course utilizes fully immersive high-fidelity simulations to train CCATT personnel and assess their readiness for deployment. This study aims to (1) determine whether these simulations correctly discriminate between students with previous deployment experience ("experienced") and no deployment experience ("novices") and (2) examine the effects of students' clinical practice environment on their performance during training simulations. MATERIALS AND METHODS: Critical Care Air Transport Team Advanced student survey data and course status (pass/no pass) between March 2006 and April 2020 were analyzed. The data included students' specialty, previous exposure to the CCATT Advanced course, previous CCATT deployment experience, years in clinical practice (<5, 5-15, and >15 years), and daily practice of critical care (yes/no), as well as a description of the students' hospital to include the total number of hospital (<100, 100-200, 201-400, and >400) and intensive care unit (0, 1-10, 11-20, and >20) beds. Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCATT Advanced course. RESULTS: A total of 2,723 surveys were analyzed: 841 (31%) were physicians (MDs), 1,035 (38%) were registered nurses, and 847 (31%) were respiratory therapists (RTs); 641 (24%) of the students were repeating the course for sustainment training and 664 (24%) had previous deployment experience. Grouped by student specialty, the MDs', registered nurses', and RTs' pass rates were 92.7%, 90.6%, and 85.6%, respectively. Multivariable regression results demonstrated that deployment experience was a robust predictor of passing. In addition, the >15 years in practice group had a 47% decrease in the odds of passing as compared to the 5 to 15 years in practice group. Finally, using MDs as the reference, the RTs had a 61% decrease in their odds of passing. The daily practice of critical care provided a borderline but nonsignificant passing advantage, whereas previous CCATT course exposure had no effect. CONCLUSION: Our primary result was that the CCATT Advanced simulations that are used to evaluate whether the students are mission ready successfully differentiated "novice" from "experienced" students; this is consistent with valid simulation constructs. Finally, novice CCATT students do not sustain their readiness skills during the period between mandated refresher training.

Broiler growth and efficiency in response to relaxed maternal feed restriction.

Broiler growth performance can be influenced by maternal BW, maternal age, and sex. The present study evaluated broiler growth and efficiency in response to increased maternal BW (relaxed level of maternal feed restriction). It was hypothesized that BW and fatness would increase, and efficiency would be reduced as maternal BW increased. Ten BW trajectories were applied to precision-fed Ross 708 female broiler breeders (n = 30) from 2 to 42 wk of age. Trajectories varied in prepubertal and pubertal growth phases from 2.5 to 22.5% above the recommended BW target. Additional unrestricted breeders (n = 6) were not limited to a maximum BW (fed ad libitum). Two 35 d experiments were conducted with precision-fed broilers from these breeders at 35 and 42 wk of age. Two analyses (full and restricted analysis scopes) were performed to evaluate broiler BW, feed conversion ratio (FCR) and carcass traits with maternal BW at photostimulation (22 wk of age) as a continuous effect, and maternal age and sex as discrete effects. The full scope included broilers from all hens (feed restricted and unrestricted). The restricted scope excluded broilers from unrestricted hens. Differences were reported at P ≤ 0.05. For every kilogram increase in maternal BW, cumulative FCR increased by 0.235 and 0.471 g:g for broilers from all and feed restricted hens, respectively. Proportional gut weight of broilers from feed restricted hens decreased by 0.8244% per kilogram increase in maternal BW. Males were heavier than females on day 28 and 35, and broilers from 42-wk-old breeders were heavier than broilers from 35-wk-old breeders on day 0 and 35. Males from all hens were more feed efficient (1.318 g:g) than females (1.335 g:g) from day 29 to 35. Females from all and feed restricted hens had a greater proportional fat pad and breast muscle weight than males, and proportional breast muscle yield of broilers from 42-wk-old breeders was on average 1.04 times greater than that of broilers from 35-wk-old breeders. Maternal BW did not affect offspring BW, reduced cumulative FCR, and reduced gut weight in the restricted analysis scope.

Feeding, feed-seeking behavior, and reproductive performance of broiler breeders under conditions of relaxed feed restriction.

Broiler breeders are feed restricted to optimize reproductive performance. A randomized controlled study was conducted to investigate the effect of increasing female broiler breeder BW on feeding, feed-seeking behavior, and reproductive performance. It was hypothesized that a greater BW would decrease feeding and feed-seeking behavior, and reduce reproductive performance. Ross 708 female broiler breeders (n = 36) were fed using a precision feeding system from 2 to 42 wk of age. Ten BW trajectories were created from a multiphasic Gompertz growth model that increased growth from 0 to 22.5% in the prepubertal and pubertal phases of growth, in 2.5% increments. Six unrestricted birds were not limited to a maximum BW. Body weight was evaluated as a 2-way ANOVA. Two linear regression analyses were conducted, one which included all birds and one which excluded the unrestricted birds. For the regression analyses, BW at photostimulation (22 wk of age) was used as the continuous independent variable to represent the degree of variation between trajectories. Differences were reported at P ≤ 0.05. Body weight increased as trajectory-specific BW targets increased from 6 to 28 wk of age. Differences of BW between BW trajectories decreased during the laying period, which was a result of individual bird variation within BW trajectories. Station visit frequency decreased per kilogram increase in BW for all birds during rearing and lay, and within feed-restricted birds during lay only. The number of meals and ADFI increased with age, which reflected nutrient intake to support maintenance, growth, and reproductive requirements. Mean egg weight (EW) of all birds increased by 0.72 g per kilogram increase in BW from 22 to 41 wk of age. From 22 to 29 wk of age, mean EW of feed-restricted birds increased by 2.78 g per kilogram increase in BW. For every kilogram increase in BW, age at first egg comparing all birds decreased by 10.83 d. Two unrestricted birds came into lay before photostimulation. In contrast with the hypotheses, BW increased up to 22.5% above the recommended target did not reduce feeding and feed seeking behavior, or negatively impact reproductive performance.

A model of pre-pubertal broiler breeder estradiol-17ß levels predicts advanced sexual maturation for birds with high body weight or short juvenile day-length exposure.

As broiler breeders face increased reproductive challenges specifically related to overfeeding, a clear understanding of the physiological effects of BW and rearing photoperiod on reproductive development is needed. The objective was to use mathematical models to compare plasma estradiol-17ß (E2) concentration to characterize the effect of BW and rearing photoperiod on E2 levels. A 2 × 3 factorial arrangement of treatments was used. Hens (n = 180) were fed with a precision feeding system to allocate feed individually to achieve the breeder-recommended BW curve (Standard) or to a BW curve reaching the 21 wk target at 18 wk (High). Hens were on 8L:16D, 10L:14D, or 12L:12D photoschedules during rearing and were photostimulated at 21 wk. Age at first egg (AFE) was recorded. Plasma E2 levels were determined weekly between week 20 and 28. Two modified Gompertz models described E2 level as a function of (a) chronological or (b) physiological (relative to AFE) age. Timing of E2-inflection point was compared between models and treatments. Differences were reported as significant at P ≤ 0.05. The chronological age model inferred that High BW reduced the duration between the E2-inflection point and AFE, whereas the physiological age model inferred that High BW only reduced the duration between photostimulation and the E2-inflection point. Hens on the Standard BW treatment had a longer period between photostimulation and the E2-inflection point compared to hens on the High-BW treatment (11.03 vs. 1.50 wk, respectively, based on physiological age). Hens on the 12L:12D photoschedule had a longer period between photostimulation and the E2-inflection point compared to hens on the 8L:16D or 10L:14D photoschedule, both in the Standard and High BW (28.91 vs. 1.78 and 2.40 wk, 2.65 vs. 0.93 and 0.94 wk, respectively, based on physiological age). The described methodology and results provide quantitative insight into E2 dynamics and serves as a model for future endocrinological studies in poultry reproduction.

A nonlinear mathematical model of cell-mediated immune response for tumor phenotypic heterogeneity.

Human cancers display intra-tumor heterogeneity in many phenotypic features, such as expression of cell surface receptors, growth, and angiogenic, proliferative, and immunogenic factors, which represent obstacles to a successful immune response. In this paper, we propose a nonlinear mathematical model of cancer immunosurveillance that takes into account some of these features based on cell-mediated immune responses. The model describes phenomena that are seen in vivo, such as tumor dormancy, robustness, immunoselection over tumor heterogeneity (also called "cancer immunoediting") and strong sensitivity to initial conditions in the composition of tumor microenvironment. The results framework has as common element the tumor as an attractor for abnormal cells. Bifurcation analysis give us as tumor attractors fixed-points, limit cycles and chaotic attractors, the latter emerging from period-doubling cascade displaying Feigenbaum's universality. Finally, we simulated both elimination and escape tumor scenarios by means of a stochastic version of the model according to the Doob-Gillespie algorithm.

Preliminary Study of the Effects of Sequential Hypoxic Exposures in a Simulated Flight Task.

BACKGROUND: Previous studies of acute hypoxia have largely examined different altitudes in isolation. Pilots, however, receive two exposures during in-flight hypoxic emergencies (IFHEs): the initial exposure at altitude, followed by a second mild exposure after descending and removing the breathing mask. Conventional wisdom holds that performance recovers with blood oxygen saturation and that exposure to mild hypoxia is safe. This study examined the possibility that the effects of moderate hypoxia may linger to overlap with the effects of mild hypoxia during sequential exposures such as those experienced by pilots during an IFHE.METHODS: Subjects performed a simulated flight task and secondary task while being exposed to normobaric hypoxia via the ROBD-2.RESULTS: Average error on the flight task during exposure to 3048 m (10,000 ft) was marginally worse when preceded by exposure to 7620 m (25,000 ft; 7.40 ± 3.32) than when experienced in isolation (6.42 ± 3.82). Performance on the secondary task was likewise worse when the mild exposure followed the moderate exposure (0.27 ± 0.30 lapses per minute) than when the mild exposure occurred by itself (0.19 ± 0.20 lapses per minute). Minimum Spo2 showed a similar pattern of results (84.87 ± 4.37 vs. 86.61 ± 2.47).DISCUSSION: We believe our results are most likely due to a failure to recover from the original moderate exposure rather than an additive effect between the exposures. Even so, our findings suggest that pilot impairment following an IFHE may be worse than previously believed.Robinson FE, Horning D, Phillips JB. Preliminary study of the effects of sequential hypoxic exposures in a simulated flight task. Aerosp Med Hum Perform. 2018; 89(12):1050-1059.

Early photostimulation at the recommended body weight reduced broiler breeder performance.

To synchronize the onset of sexual maturity in the face of high BW variation, the age at photostimulation has been increasing in the broiler breeder industry. This experiment studied the effects of increased BW and earlier photostimulation on broiler breeder reproductive performance where within-treatment BW uniformity was very high. The experiment tested BW and age at photostimulation treatments in a 2 × 2 factorial arrangement. Hens (n = 120) were fed with a precision feeding system to allocate feed individually following the breeder-recommended target BW (Standard) or to a 22% heavier target BW curve reaching the Standard 21 wk BW at 18 wk (High). Hens were photostimulated at either 18 wk (18WK) or 21 wk (21WK) with a 16L:8D photoschedule. Age at first egg (AFE) and individual egg production to 55 wk were recorded. Differences were reported as significant if P ≤ 0.05. The AFE was decreased and maturation interval between photostimulation and AFE was shorter for hens on the High BW treatment compared to the Standard BW treatment (178.1 vs. 194.7 d and 41.8 vs. 58.2 d, respectively). Hens on the 21WK treatment had a decreased AFE compared to the 18WK treatment (177.0 d vs. 195.9 d) and their maturation interval was shorter (30.0 d vs. 69.9 d). The CV for AFE was higher in the 18WK treatment compared to the 21WK treatment (28.2% vs. 11.2%). Total egg production was higher for hens on the High BW treatment compared to the Standard BW treatment (129.4 vs. 92.8, respectively). Total egg production was higher for hens on the 21WK treatment compared to the 18WK treatment (138.4 vs. 83.8, respectively). Egg weight of Standard BW × 18WK hens was lower compared to High BW × 18WK hens. Current recommended breeder BW may be too low for optimal sexual maturation after photostimulation. It is concluded that even when BW variation is minimized, photostimulation at 18 wk of age is not recommended.

Feasibility of measuring memory response to increasing dexmedetomidine sedation in children.

BACKGROUND: The memory effect of dexmedetomidine has not been prospectively evaluated in children. We evaluated the feasibility of measuring memory and sedation responses in children during dexmedetomidine sedation for non-painful radiological imaging studies. Secondarily, we quantified changes in memory in relation to the onset of sedation. METHODS: A 10 min bolus of dexmedetomidine (2 mcg kg-1) was given to children as they named simple line drawings every five s. The absence of sedation was identified as any verbal response, regardless of correctness. After recovery, recognition memory was tested with correct Yes/No recognitions (50% novel pictures) and was matched to sedation responses during the bolus period (subsequent memory paradigm). RESULTS: Of 64 accruals, 30 children (mean [SD]6.1 (1.2) yr, eight male) received dexmedetomidine and completed all study tasks. Individual responses were able to be modelled successfully in the 30 children completing all the study tasks, demonstrating feasibility of this approach. Children had 50% probability of verbal response at five min 40 s after infusion start, whereas 50% probability of subsequent recognition memory occurred sooner at four min five s. CONCLUSIONS: Quantifying memory and sedation effects during dexmedetomidine infusion in verbal children was possible and demonstrated that memory function was present until shortly before verbal unresponsiveness occurred. This is the first study to investigate the effect of dexmedetomidine on memory in children. CLINICAL TRIAL REGISTRATION: NCT 02354378.

Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition.

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

Reliability of 24-h void frequency as an index of hydration status when euhydrated and hypohydrated.

BACKGROUND/OBJECTIVES: Void frequency (VF) is significantly correlated to hydration status, but it is unknown whether VF is reliable when an individual is repeatedly euhydrated (EU) or hypohydrated (HY). The purpose of this study was to test the reliability of VF when individuals were EU or HY on multiple occasions. SUBJECTS/METHODS: Fourteen males (age 22±2 years, mass 79.1±12.8 kg) completed three EU trials achieved with 24-h ad libitum fluid intake, and 14 males (age 22±2 years, mass 78.6±10.4 kg) completed three HY trials achieved with 24-h fluid restriction. Twenty-four hour urine was collected and analyzed for specific gravity (USG) and VF. Subjects voided at a 'normal urgency' (rated a '2' on a 0-4 perceptual scale) throughout each 24-h period. RESULTS: Twenty-four hour USG was greater and VF was lower when HY (1.026±0.003 and 5±2, respectively) versus EU (1.014±0.003 and 7±2; both P<0.05). Intra-class correlations for VF between the three trials at each hydration status were deemed acceptable (0.863 and 0.849 for EU and HY, respectively). Within-subject coefficients of variation for VF were 15±9 and 21±14% for the EU and HY trials. CONCLUSIONS: VF is a reliable index of 24-h hydration status when healthy young males are EU or HY and voiding at a consistent 'urgency'.

Effect of passive heat stress on arterial stiffness in smokers versus non-smokers.

In non-smokers, passive heat stress increases shear stress and vasodilation, decreasing arterial stiffness. Smokers, who reportedly have arterial dysfunction, may have similar improvements in arterial stiffness with passive heat stress. Therefore, we examined the effects of an acute bout of whole-body passive heat stress on arterial stiffness in smokers vs. non-smokers. Thirteen smokers (8.8 ± 5.5 [median = 6] cigarettes per day for > 4 years) and 13 non-smokers matched for age, mass, height, and exercise habits (27 ± 8 years; 78.8 ± 15.4 kg; 177.6 ± 6.7 cm) were passively heated to 1.5 °C core temperature (T C) increase. At baseline and each 0.5 °C T C increase, peripheral (pPWV) and central pulse wave velocity (cPWV) were measured via Doppler ultrasound. No differences existed between smokers and non-smokers for any variables (all p > .05), except cPWV slightly increased from baseline (526.7 ± 81.7 cm · s(-1)) to 1.5 °C ΔT C (579.7 ± 69.8 cm · s(-1); p < 0.005), suggesting heat stress acutely increased central arterial stiffness. pPWV did not change with heating (grand mean: baseline = 691.9 ± 92.9 cm · s(-1); 1.5 °C ΔT C = 691.9 ± 79.5 cm · s(-1); p > 0.05). Changes in cPWV and pPWV during heating correlated (p < 0.05) with baseline PWV in smokers (cPWV: r = -0.59; pPWV: r = -0.62) and non-smokers (cPWV: r = -0.45; pPWV: r = -0.77). Independent of smoking status, baseline stiffness appears to mediate the magnitude of heating-induced changes in arterial stiffness.

Effects of broiler breeder management on pullet body weight and carcass uniformity.

An experiment was conducted to study the effect of broiler breeder feeding management practices on pullet performance, BW uniformity, and carcass traits during rearing (to 22 wk of age). At 3 wk of age, 1,200 Ross 308 breeder pullets were assigned to one of 5 treatments: 1) control: standard mash diet, fed daily; 2) high fiber: mash diet containing 25% lower nutrient density, fed daily; 3) scatter: standard diet in pellet form scattered on litter, fed daily; 4) skip-a-day: standard mash diet, fed on alternate days; or 5) grading: standard mash diet, fed daily (birds sorted into low, average, and high BW groups every 4 wk). Birds on the high fiber treatment consumed more feed (P<0.0001) and had the highest feed conversion ratio (FCR; P<0.004) but the lowest ME to gain and CP to gain ratios (P≤0.002). Skip-a-day treatment pullets consumed more ME and CP than birds in any other treatment (P<0.001). Grading yielded the highest BW uniformity at 22 wk of age (CV=6.2%), while control and high fiber treatment groups were least uniform (CV>15%; P<0.0001). Skip-a-day feed restriction produced birds with the significantly lowest breast muscle and highest liver weight compared to all other treatments (P<0.05). Variation in shank length, chest width, and breast muscle was lowest in the grading treatment, whereas the CV for fat pad and liver was lowest in the skip-a-day treatment. In this trial, broiler breeder target BW profiles were achieved using combinations of quantitative and qualitative feed restriction, or preemptive management practices. Qualitative diet dilution and skip-a-day management did little to increase flock uniformity relative to the control during the most intense period of feed restriction (7 to 19 wk). Scatter feeding increased flock uniformity to a small degree, whereas grading yielded the highest increase in BW and carcass trait uniformity.