A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives.

PURPOSE: As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success. METHODS: Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data. FINDINGS: Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

Ultrafast laser inscribed waveguides in tailored fluoride glasses: an enabling technology for mid-infrared integrated photonics devices.

Zirconium fluoride (ZBLAN) glass, the standard material used in fiber-based mid-infrared photonics, has been re-designed to enable the fabrication of high index-contrast low-loss waveguides via femtosecond laser direct writing. We demonstrate that in contrast to pure ZBLAN, a positive index change of close to 10-2 can be induced in hybrid zirconium/hafnium (Z/HBLAN) glasses during ultrafast laser inscription and show that this can be explained by an electron cloud distortion effect that is driven by the existence of two glass formers with contrasting polarizability. High numerical aperture (NA) type-I waveguides that support a well confined 3.1 µm wavelength mode with a mode-field diameter (MFD) as small as 12 µm have successfully been fabricated. These findings open the door for the fabrication of mid-infrared integrated photonic devices that can readily be pigtailed to existing ZBLAN fibers.

Rational and design of the T-STORHM Study: A prospective randomized trial comparing fresh whole blood to blood components for acutely bleeding trauma patients.

Massive hemorrhage remains the main cause of preventable death in combat settings and is also the main cause of year loss in developing countries. The management of these patients relies on blood transfusion and surgery. Time is a key factor, related to survival. Recent events highlight the need to be more efficient in the transfusion supply during terror attacks or mass casualties in civilian settings. Blood components therapy with a 1:1:1 ratio is associated with a decrease of mortality but encounters many logistic issues in those circumstances. Whole blood provides in one bag all the blood components in physiologic proportions with minimal amount of additive solution. Whole blood has been implemented in military as well as civilian settings worldwide. However, direct comparisons with component therapy in prospective clinical trials are scarce. Here we present the rational and the design of the T-STORHM (Trauma-Sang TOtal dans les Hémorragies Massives) trial. This prospective randomized multicentric clinical trial will test low titer group O whole blood to components therapy in the in-hospital management of trauma patients with massive hemorrhage. Sample size calculation, primary and secondary endpoints as trial blood products preparations are discussed. The trial is expected to start in 2019 in 6 civilians and military trauma centers. The French Military Health Service is promoting the study in collaboration with the French transfusion public service (Établissementfrançaisdusang).

[Preparation of pooled granulocytes concentrates from whole blood buffy coats (PGC) as an alternative to apheresis]. / Le mélange de concentré de granulocytes de sang total (MCGST) comme alternative au concentré de granulocytes d'aphérèse (CGA).

BACKGROUND: The collection of granulocytes by apheresis requires volunteer donor stimulation by corticoids and the use of HES, a compound which is currently challenged by potential safety issues. Preparation of pooled granulocytes concentrates from whole blood buffy coats (PGC) represent an alternative to apheresis with a better benefit/risk for the donors. METHOD: Whole blood is collected in a bottom and top blood bag for buffy coat preparation. After centrifugation and separation, buffy coat are obtained. Twenty ABO matched buffy coats are selected for processing into one PGC. Four pools of five buffy coats were made, platelet additive solution is added to each pool, mixed gently and centrifuged. The red cell residue, supernatant and granulocyte rich layer are separated. Two granulocyte rich layers are pooled and added with 70mL of ABO matched plasma from the initial donations (=PGC10). The final PGC (=PGC20) is obtained by pooling two PGC10 into a platelet storage bag. Neutrophil content and in-vitro functionality are assessed at day of preparation (D1) and at expiry hour, 48 hours after collection (D2). RESULTS: On N=18, mean: Volume=408±4mL, 2.2*1010±0.24 neutrophils, Hematocrit=18%±3%, 4.7*1011platelets. Viability is well preserved: 95%±6% day of PGC preparation, 85%±7% after 24h of storage (D2). Functionality (ROS production measurement) is well preserved: 1.36±0.25 at D1 and 1.38±0.18 at D2. Expression and modulation of adhesion molecules after stimulation are normal at D1 and slightly decreased at D2 but still normal. CONCLUSIONS: PGC20 in vitro characteristics are in conformance with the EDQM guide (V19) and similar to apheresis for granulocytes content and hematocrit. The viability and two mean indicators which explore neutrophil function are well maintained during PGC preparation and after 24 hours of storage.

Periconception weight management in the Women, Infants, and Children program.

INTRODUCTION: Reproductive age women, particularly low-income and minority women, are at risk for obesity. As an integral service provider for these women, the US Department of Agriculture Special Supplemental Nutrition Program for Women, Infants, and Children is uniquely positioned to refine its focus and efforts. METHODS: Strategies for accomplishing this goal include identifying pregnant, inter-partum and post-partum women in need of targeted patient-centred services including education, counselling and support to address weight loss or appropriate gestational weight gain. RESULTS: These services may include calorie-controlled diets, behavioural strategies, alternative methods of education delivery and extending post-partum benefits. Implementation of these strategies is feasible through collaboration with related government subsidized programs and reallocation of funds, staff and other resources. CONCLUSIONS: Given the magnitude of the problem and the adverse outcomes that obesity has on health and quality of life, Women, Infants, and Children can more positively impact the lives of our most vulnerable families, which face an obesogenic environment.

Wide-area transepithelial sampling with computer-assisted 3-dimensional analysis (WATS) markedly improves detection of esophageal dysplasia and Barrett's esophagus: analysis from a prospective multicenter community-based study.

The 4-quadrant forceps biopsy (FB) protocol for identifying Barrett's esophagus (BE) and esophageal dysplasia (ED) suffers from poor sensitivity due to significant sampling error. We investigated the benefit of wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS) used adjunctively to the combination of random and targeted FB in the detection of ED, and as a secondary outcome, BE. In this multicenter prospective trial, community endoscopists at 21 sites utilized WATS as an adjunct to both targeted and random FB in patients undergoing BE screening and surveillance. Investigators alternated taking FB and WATS samples first. WATS specimens were analyzed at CDx Diagnostics (Suffern, NY) while FB samples were analyzed by each site's regular pathologists. Data were de-identified and then aggregated for analysis. Of 12,899 patients enrolled, FB identified 88 cases of ED, and WATS detected an additional 213 cases missed by FB. These 213 cases represented an absolute increase of 1.65%, raising the yield from 0.68% to 2.33%. Adding WATS to FB increased the overall detection of ED by 242% (95% CI: 191%-315%). Fewer than 61 patients needed to be tested with WATS to identify an additional case of ED. The combination of random and targeted FB identified 1,684 cases of BE, and WATS detected an additional 2,570 BE cases. The absolute incremental yield of adding WATS to FB is 19.9%, increasing the rate of detection from 13.1% to 33%. Adding WATS to FB increased the overall detection of BE by 153% (95% CI: 144-162%). The number needed to test with WATS in order to detect an additional case of BE was 5. Whether FB or WATS was done first did not impact the results. In this study, comprised of the largest series of patients evaluated with WATS, adjunctive use of the technique with targeted and random FB markedly improved the detection of both ED and BE. These results underscore the shortcomings of FB in detecting BE-associated neoplasia, which can potentially impact the management and clinical outcomes of these patients.

Novel concept for visible and near infrared spectro-interferometry: laser-written layered arrayed waveguide gratings.

With the growing complexity of astronomical instruments devoted to interferometry, such as MATISSE (a 4 telescope beam combiner) or FIRST (a 9 sub-apertures beam combiner), and the rebirth of space projects such as LIFE (a mid-infrared interferometer), integrated optics devices can be an interesting and complementary approach for beam combination of a large number of apertures. Moreover, one of the approaches for beam combination is pairwise combination of the inputs (either from individual telescopes or from aperture masking on a single telescope), which scales as N(N-1)/2 for an N input system. Astrophotonics devices are attractive to reduce mass and system complexity, while achieving all the beam combination in a single chip, even for a high number of inputs. The aim of this work is to develop a compact photonic device for astronomical applications and demonstrate a proof-of-concept of a spectro-interferometer. In this paper ultrafast laser inscription is used to fabricate three arrayed waveguide gratings (AWGs) stacked vertically. This arrangement enables spectral dispersion and interferometry to be measured simultaneously. Individual AWGs were designed for operation at 633 nm, and demonstrated at 633nm and 830nm. A scan between 790 and 830nm was also achieved to study the wavelength behavior of the AWG. Using a segmented mirror, light at 633nm or 830nm was injected simultaneously into three AWGs layered 40 µm apart, showing analogous behavior for all three layers and no unexpected crosstalk. Finally the three outputs were vertically combined to obtain interference fringes, showing the feasibility of spectro-interferometry and opening the way for compact astrophotonic devices devoted to phase closure studies, used in astronomy to reduce the effect of atmospheric turbulence.

[Comparative study on platelet transfusion in Lorraine-Champagne and Alsace in 2015]. / Étude comparative des transfusions de concentrés plaquettaires en Alsace et en Lorraine-Champagne en 2015.

OBJECTIVES: To find explanations for the observed differences of platelets concentrates (PC) deliveries between 2 French regions, Lorraine-Champagne (LOCH) and Alsace (ALSA). METHODS: This is a non-interventional prospective study, performed during 30 days in 2015 in intensive care, cardiovascular surgery and onco-hematological wards of 8 LOCH and ALSA hospitals. Questionnaires listing clinical and biological parameters were attached to the prescription forms and filled in at each PC prescription. RESULTS: In all, 290 patients, 1093 prescriptions and 1093 deliveries of PC were analyzed. The pre-transfusional context (patient weight, prophylactic or curative situation, pre-transfusional platelet count) were homogenous. The phasing of the prescription forms wording had a direct impact on the doses' formulation : 100 % of the LOCH forms were expressed in platelet quantity (PQ), vs 22 % in ALSA. The mean interval between 2 transfusions was 2.9 days in ALSA vs 4.9 days in LOCH. The mean PQ/delivery was higher in ALSA (5.6.1011 vs 4.0.1011 in LOCH). The delivered PQs were compared to the 2003 French recommendations that were in force in 2015. Twenty-seven percent of the LOCH delivered PQs were in the recommended interval, vs Forty-nine percent in ALSA. Due to the systematic delivery of a single PC unit, including weights>80Kg, LOCH presented 63 % insufficient PQ deliveries. Twenty-two percent of the deliveries in ALSA were over the recommended interval, mostly linked with the simultaneous delivery of a second PC. CONCLUSION: This study identifies disparities in terms of prescription and delivery between LOCH and ALSA, which may explain their respective PC consumption levels.

Femtosecond laser written arrayed waveguide gratings with integrated photonic lanterns.

We demonstrate for the first time functional arrayed waveguide gratings (AWGs) fabricated using the femtosecond laser direct-write technique. This fabrication technique is a mask-less alternative to lithography enabling design flexibility and rapid prototyping. It is ideal for customized small scale production for new applications. The devices were demonstrated in the visible region at 632.8 nm with a measured free spectral range (FSR) of 22.2 nm, and 1.35 nm resolution. To highlight the advantages of using a 3-dimensional fabrication technique, a 3-port photonic lantern was integrated with an AWG in a single monolithic chip. Integration of this type is not feasible with lithography-based AWG fabrication and can increase the functionality of AWGs for sensing applications.

Effects of a program of cognitive-behavioural group therapy, vestibular rehabilitation, and psychoeducational explanations on patients with dizziness and no quantified balance deficit, compared to patients with dizziness and a quantified balance deficit.

BACKGROUND: We examined whether a program combining cognitive-behavioural therapy (CBT), vestibular rehabilitation (VR) and psychoeducation is equally effective in improving psychometric measures in patients with dizziness independent of a balance deficit. Measures of patients with dizziness only (DO) were compared to those of patients also having a quantified balance deficit (QBD). METHODS: 32 patients (23 female, 9 male) with persistent dizziness were analysed as 2 groups based on stance and gait balance control: those with QBD (pathological balance) or DO (normal balance). Dizziness Handicap Inventory (DHI) and Brief Symptom Inventory (BSI) questionnaires were used pre- and post-therapy to assess psychometric measures. Patients then received the same combination therapy in a group setting. RESULTS: The QBD group mean age was 60.6, SD 8.3, and DO group mean age 44.8, SD 12.1, years. Pre-therapy, questionnaire scores were pathological but not different between groups. Balance improved significantly for the QBD group (p=0.003) but not for the DO group. DHI and BSI scores improved significantly in the DO group (0.001

Cardiopulmonary fitness is strongly associated with body cell mass and fat-free mass: The Study of Health in Pomerania (SHIP).

Peak oxygen uptake (VO2peak) is commonly indexed by total body weight (TBW) to determine cardiopulmonary fitness (CPF). This approach may lead to misinterpretation, particularly in obese subjects. We investigated the normalization of VO2peak by different body composition markers. We analyzed combined data of 3848 subjects (1914 women; 49.7%), aged 20-90, from two independent cohorts of the population-based Study of Health in Pomerania (SHIP-2 and SHIP-TREND). VO2peak was assessed by cardiopulmonary exercise testing. Body cell mass (BCM), fat-free mass (FFM), and fat mass (FM) were determined by bioelectrical impedance analysis. The suitability of the different markers as a normalization variable was evaluated by taking into account correlation coefficients (r) and intercept (α-coefficient) values from linear regression models. A combination of high r and low α values was considered as preferable for normalization purposes. BCM was the best normalization variable for VO2peak (r = .72; P ≤ .001; α-coefficient = 63.3 mL/min; 95% confidence interval [CI]: 3.48-123) followed by FFM (r = .63; P ≤ .001; α-coefficient = 19.6 mL/min; 95% CI: -57.9-97.0). On the other hand, a much weaker correlation and a markedly higher intercept were found for TBW (r = .42; P ≤ .001; α-coefficient = 579 mL/min; 95% CI: 483 to 675). Likewise, FM was also identified as a poor normalization variable (r = .10; P ≤ .001; α-coefficient = 2133; 95% CI: 2074-2191). Sex-stratified analyses confirmed the above order for the different normalization variables. Our results suggest that BCM, followed by FFM, might be the most appropriate marker for the normalization of VO2peak when comparing CPF between subjects with different body shape.

Pitfalls in accelerometer-based measurement of physical activity: The presence of reactivity in an adult population.

When a behavior is monitored, it is likely to change, even if no change may be intended. This phenomenon is known as measurement reactivity. We investigated systematic changes in accelerometer-based measures over the days of monitoring as an indicator of measurement reactivity in an adult population. One hundred seventy-one participants from the general population (65% women; mean age = 55 years, range: 42-65 years) wore accelerometers for 7 consecutive days to measure sedentary behavior and physical activity (PA). Latent growth models were used (a) to investigate changes in accelerometer wear time over the measurement days and (b) to identify measurement reactivity indicated by systematic changes in sedentary time (ST), light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). Over the measurement days, participants reduced accelerometer wear time by trend (rate of change [b] = -4.7 min/d, P = .051, Cohen's d = .38), increased ST (b = 2.4 min/d, P = .018, d = .39), and reduced LPA (b = -2.4 min/d, P = .015, d = .38). Participants did not significantly reduce MVPA (P = .537). Our data indicated that accelerometry might generate reactivity. Small effects on ST and LPA were found. Thus, the validity of accelerometer-based data on ST and LPA may be compromised. Systematic changes observed in accelerometer wear time may further bias accelerometer-based measures. MVPA seems to be less altered due to the presence of an accelerometer.

Modal noise in an integrated photonic lantern fed diffraction-limited spectrograph.

In an attempt to develop a streamlined astrophotonic instrument, we demonstrate the realization of an all-photonic device capable of both multimode to single mode conversion and spectral dispersion on an 8-m class telescope with efficient coupling. The device was a monolithic photonic spectrograph which combined an integrated photonic lantern and an efficient arrayed waveguide grating device. During on-sky testing, we discovered a previously unreported type of noise that made spectral extraction and calibration extremely difficult. The source of the noise was traced to a wavelength-dependent loss mechanism between the feed fiber's multimode near-field pattern and the modal acceptance profile of the integrated photonic lantern. Extensive modeling of the photonic components replicates the wavelength-dependent loss, and demonstrates an identical effect on the final spectral output. We outline that this could be mitigated by directly injecting into the integrated photonic lantern.

Demonstration of an efficient, photonic-based astronomical spectrograph on an 8-m telescope.

We demonstrate for the first time an efficient, photonic-based astronomical spectrograph on the 8-m Subaru Telescope. An extreme adaptive optics system is combined with pupil apodiziation optics to efficiently inject light directly into a single-mode fiber, which feeds a compact cross-dispersed spectrograph based on array waveguide grating technology. The instrument currently offers a throughput of 5% from sky-to-detector which we outline could easily be upgraded to ∼ 13% (assuming a coupling efficiency of 50%). The isolated spectrograph throughput from the single-mode fiber to detector was 42% at 1550 nm. The coupling efficiency into the single-mode fiber was limited by the achievable Strehl ratio on a given night. A coupling efficiency of 47% has been achieved with ∼ 60% Strehl ratio on-sky to date. Improvements to the adaptive optics system will enable 90% Strehl ratio and a coupling of up to 67% eventually. This work demonstrates that the unique combination of advanced technologies enables the realization of a compact and highly efficient spectrograph, setting a precedent for future instrument design on very-large and extremely-large telescopes.

[Prevention of anemia in blood donors]. / Prévention de l'anémie chez les donneurs de sang.

The prevention of anemia of blood donor is a main issue for donor safety and self-supplying. This prevention is done in one hand by donor deferral whose haemoglobin level is under defined threshold and in other hand by preventing iron deficiency. Some subgroups of donors are at increased risk for developing iron deficiency and adverse effects of iron deficiency: premenopausal females; donors with haemoglobin values near the minimum for eligibility and frequent donors. Different interventions could be used: lengthening the inter-donational interval and/or decreasing the number of donations per year; donor ferritin testing to evaluate iron store and at least donor iron supplementation.

Clinical experience with single-nucleotide polymorphism-based non-invasive prenatal screening for 22q11.2 deletion syndrome.

OBJECTIVES: To evaluate the performance of a single-nucleotide polymorphism (SNP)-based non-invasive prenatal test (NIPT) for the detection of fetal 22q11.2 deletion syndrome in clinical practice, assess clinical follow-up and review patient choices for women with high-risk results. METHODS: In this study, 21 948 samples were submitted for screening for 22q11.2 deletion syndrome using a SNP-based NIPT and subsequently evaluated. Follow-up was conducted for all cases with a high-risk result. RESULTS: Ninety-five cases were reported as high risk for fetal 22q11.2 deletion. Diagnostic testing results were available for 61 (64.2%) cases, which confirmed 11 (18.0%) true positives and identified 50 (82.0%) false positives, resulting in a positive predictive value (PPV) of 18.0%. Information regarding invasive testing was available for 84 (88.4%) high-risk cases: 57.1% (48/84) had invasive testing and 42.9% (36/84) did not. Ultrasound anomalies were present in 81.8% of true-positive and 18.0% of false-positive cases. Two additional cases were high risk for a maternal 22q11.2 deletion; one was confirmed by diagnostic testing and one had a positive family history. There were three pregnancy terminations related to screening results of 22q11.2 deletion, two of which were confirmed as true positive by invasive testing. CONCLUSIONS: Clinical experience with this SNP-based non-invasive screening test for 22q11.2 deletion syndrome indicates that these deletions have a frequency of approximately 1 in 1000 in the referral population with most identifiable through this test. Use of this screening method requires the availability of counseling and other management resources for high-risk pregnancies.

Holmium-doped 2.1 µm waveguide chip laser with an output power > 1 W.

We demonstrate the increasing applicability of compact ultra-fast laser inscribed glass guided-wave lasers and report the highest-power glass waveguide laser with over 1.1 W of output power in monolithic operation in the short-infrared near 2070 nm achieved (51% incident slope efficiency). The holmium doped ZBLAN chip laser is in-band pumped by a 1945 nm thulium fiber laser. When operated in an extended-cavity configuration, over 1 W of output power is realized in a linearly polarized beam. Broad and continuous tunability of the extended-cavity laser is demonstrated from 2004 nm to 2099 nm. Considering its excellent beam quality of M² = 1.08, this laser shows potential as a flexible master oscillator for single frequency and mode-locking applications.

[ADHD in adulthood: Diagnostics and therapy]. / ADHS im Erwachsenenalter : Diagnostik und Therapie.

Traditionally, attention deficit hyperactivity disorder (ADHD) was assumed to be a childhood disorder. In the meantime a persistence of symptoms into adulthood has been shown in 60% of those affected. Besides the core symptoms of inattentiveness, hyperactivity and impulsivity, adults with ADHD often suffer from comorbid disorders and functional impairment in multiple domains. In recent years diagnostic guidelines and standardized questionnaires have been developed, which facilitate the diagnostics of ADHD. In addition various therapeutic approaches have emerged and randomized controlled studies have demonstrated the efficacy. The aim of the article is to present the current standard of knowledge with respect to the diagnostics and treatment of ADHD.

Spectral narrowing of Yb:YAG waveguide lasers through hybrid integration with ultrafast laser written Bragg gratings.

Laser written waveguides in crystalline materials can be used to make highly efficient, high gain lasers. The bi-directional emission from such lasers however is typically broadband with poor spectral control. Hybridizing a tapered, mode matched laser written Bragg grating with a broadband Yb:YAG crystalline waveguide laser, we demonstrate single longitudinal mode output from one end of the device. Careful control of the grating characteristics led to laser thresholds below 90 mW, slope efficiencies greater than 42% and output powers greater than 20 mW.