Integrated optical frequency division for microwave and mmWave generation.

The generation of ultra-low-noise microwave and mmWave in miniaturized, chip-based platforms can transform communication, radar and sensing systems1-3. Optical frequency division that leverages optical references and optical frequency combs has emerged as a powerful technique to generate microwaves with superior spectral purity than any other approaches4-7. Here we demonstrate a miniaturized optical frequency division system that can potentially transfer the approach to a complementary metal-oxide-semiconductor-compatible integrated photonic platform. Phase stability is provided by a large mode volume, planar-waveguide-based optical reference coil cavity8,9 and is divided down from optical to mmWave frequency by using soliton microcombs generated in a waveguide-coupled microresonator10-12. Besides achieving record-low phase noise for integrated photonic mmWave oscillators, these devices can be heterogeneously integrated with semiconductor lasers, amplifiers and photodiodes, holding the potential of large-volume, low-cost manufacturing for fundamental and mass-market applications13.

Integrated photonic molecule Brillouin laser with a high-power sub-100-mHz fundamental linewidth.

Photonic integrated lasers with an ultra-low fundamental linewidth and a high output power are important for precision atomic and quantum applications, high-capacity communications, and fiber sensing, yet wafer-scale solutions have remained elusive. Here we report an integrated stimulated Brillouin laser (SBL), based on a photonic molecule coupled resonator design, that achieves a sub-100-mHz fundamental linewidth with greater than 10-mW output power in the C band, fabricated on a 200-mm silicon nitride (Si3N4) CMOS-foundry compatible wafer-scale platform. The photonic molecule design is used to suppress the second-order Stokes (S2) emission, allowing the primary lasing mode to increase with the pump power without phase noise feedback from higher Stokes orders. The nested waveguide resonators have a 184 million intrinsic and 92 million loaded Q, over an order of magnitude improvement over prior photonic molecules, enabling precision resonance splitting of 198 MHz at the S2 frequency. We demonstrate S2-suppressed single-mode SBL with a minimum fundamental linewidth of 71±18 mHz, corresponding to a 23±6-mHz2/Hz white-frequency-noise floor, over an order of magnitude lower than prior integrated SBLs, with an ∼11-mW output power and 2.3-mW threshold power. The frequency noise reaches the resonator-intrinsic thermo-refractive noise from 2-kHz to 1-MHz offset. The laser phase noise reaches -155 dBc/Hz at 10-MHz offset. The performance of this chip-scale SBL shows promise not only to improve the reliability and reduce size and cost but also to enable new precision experiments that require the high-speed manipulation, control, and interrogation of atoms and qubits. Realization in the silicon nitride ultra-low loss platform is adaptable to a wide range of wavelengths from the visible to infrared and enables integration with other components for systems-on-chip solutions for a wide range of precision scientific and engineering applications including quantum sensing, gravitometers, atom interferometers, precision metrology, optical atomic clocks, and ultra-low noise microwave generation.

Ultralow 0.034†dB/m loss wafer-scale integrated photonics realizing 720 million Q and 380 µW threshold Brillouin lasing.

We demonstrate 0.034 dB/m loss waveguides in a 200-mm wafer-scale, silicon nitride (Si3N4) CMOS-foundry-compatible integration platform. We fabricate resonators that measure up to a 720 million intrinsic Q resonator at 1615 nm wavelength with a 258 kHz intrinsic linewidth. This resonator is used to realize a Brillouin laser with an energy-efficient 380 µW threshold power. The performance is achieved by reducing scattering losses through a combination of single-mode TM waveguide design and an etched blanket-layer low-pressure chemical vapor deposition (LPCVD) 80 nm Si3N4 waveguide core combined with thermal oxide lower and tetraethoxysilane plasma-enhanced chemical vapor deposition (TEOS-PECVD) upper oxide cladding. This level of performance will enable photon preservation and energy-efficient generation of the spectrally pure light needed for photonic integration of a wide range of future precision scientific applications, including quantum, precision metrology, and optical atomic clocks.

Daily Drinking Is Associated with Increased Mortality.

BACKGROUND: There is evidence that low-level alcohol use, drinking 1 to 2 drinks on occasion, is protective for cardiovascular disease, but increases the risk of cancer. Synthesizing the overall impact of low-level alcohol use on health is therefore complex. The objective of this paper was to examine the association between frequency of low-level drinking and mortality. METHODS: Two data sets with self-reported alcohol use and mortality follow-up were analyzed: 340,668 individuals from the National Health Interview Survey (NHIS) and 93,653 individuals from the Veterans Health Administration (VA) outpatient medical records. Survival analyses were conducted to evaluate the association between low-level drinking frequency and mortality. RESULTS: The minimum risk drinking frequency among those who drink 1 to 2 drinks per occasion was found to be 3.2 times weekly in the NHIS data, based on a continuous measure of drinking frequency, and 2 to 3 times weekly in the VA data. Relative to these individuals with minimum risk, individuals who drink 7 times weekly had an adjusted hazard ratio (HR) of all-cause mortality of 1.23 (p < 0.0001) in the NHIS data, and individuals who drink 4 to 7 times weekly in the VA data also had an adjusted HR of 1.23 (p = 0.01). Secondary analyses in the NHIS data showed that the minimum risk was drinking 4 times weekly for cardiovascular mortality, and drinking monthly or less for cancer mortality. The associations were consistent in stratified analyses of men, women, and never smokers. CONCLUSIONS: The minimum risk of low-level drinking frequency for all-cause mortality appears to be approximately 3 occasions weekly. The robustness of this finding is highlighted in 2 distinctly different data sets: a large epidemiological data set and a data set of veterans sampled from an outpatient clinic. Daily drinking, even at low levels, is detrimental to one's health.

Digital Breast Tomosynthesis: Cost-Effectiveness of Using Private and Medicare Insurance in Community-Based Health Care Facilities.

OBJECTIVE: The purpose of this study was to determine whether digital breast tomosynthesis (DBT) is a cost-effective alternative to full-field digital mammography (FFDM) for both Medicare and privately insured patients undergoing screening mammography. MATERIALS AND METHODS: A retrospective data analysis was performed between July 15, 2013, and July 14, 2014, with data on women presenting for screening mammography that included any additional radiologic workup (n = 6319). Patients chose to undergo DBT or FFDM on the basis of personal preference, physician suggestion, and cost difference. The summation of findings over the 1-year period were used to calculate recall rates, cancer detection rates, and billing costs for a regional private insurer and Medicare. RESULTS: Data from the 6319 patients who participated were divided: 3655 patients underwent DBT, and 2664 underwent FFDM during the year of screening. Private insurance billing cost $2.9 million, and Medicare cost $1.2 million for screening, follow-up imaging, and radiologic procedures. Per-person costs were approximately $40 higher for the DBT group using both forms of insurance. However, cost per cancer detected was lower in the DBT group for both private and governmental insurance, leading to potentially $3.7 million and $899,000 saved per 100 cancers found. After standardization of the difference in cancer detection rates between the two groups, DBT was a cost-equivalent alternative to FFDM for private insurance billing but was a cost-inefficient alternative with respect to Medicare costs. CONCLUSION: In a community-based setting, DBT is a cost-equivalent or potentially cost-effective alternative to FFDM and has the capacity for improving cancer detection and recall rates.

Endometrial ablation: is tubal ligation a risk factor for hysterectomy.

STUDY OBJECTIVE: To determine whether tubal ligation is a risk factor for future hysterectomy after second-generation endometrial ablation. DESIGN: Retrospective chart review (Canadian Task Force classification II-3). SETTING: Resident-run clinic and private office in a community setting. PATIENTS: Five hundred eighty-seven patients who underwent endometrial ablation. INTERVENTIONS: Patients underwent endometrial ablation using either radiofrequency or thermal balloon. Data collected included age, body mass index, uterine length, and endometrial stripe, as well as smoking status and presence or absence of hypertension and hypothyroidism. Indication for hysterectomy and pathologic findings at hysterectomy were also examined. MEASUREMENTS AND MAIN RESULTS: There was no association between tubal ligation and second-generation endometrial ablation resulting in hysterectomy (p = .09). Statistically significant variables included endometrial stripe (p <.001) and smoking (p <.001). There was no statistical significance between the groups insofar as type of ablation, age, body mass index, uterine length, hypertension, or hypothyroidism. Time from endometrial ablation to hysterectomy between groups was not significant. Indication for hysterectomy and pathologic findings after hysterectomy were also not significant. CONCLUSIONS: Tubal ligation is not a statistically significant risk factor for hysterectomy after endometrial ablation. Tubal ligation does not affect the length of time from endometrial ablation to hysterectomy.

422 Million intrinsic quality factor planar integrated all-waveguide resonator with sub-MHz linewidth.

High quality-factor (Q) optical resonators are a key component for ultra-narrow linewidth lasers, frequency stabilization, precision spectroscopy and quantum applications. Integration in a photonic waveguide platform is key to reducing cost, size, power and sensitivity to environmental disturbances. However, to date, the Q of all-waveguide resonators has been relegated to below 260 Million. Here, we report a Si3N4 resonator with 422 Million intrinsic and 3.4 Billion absorption-limited Qs. The resonator has 453 kHz intrinsic, 906 kHz loaded, and 57 kHz absorption-limited linewidths and the corresponding 0.060 dB m-1 loss is the lowest reported to date for waveguides with deposited oxide upper cladding. These results are achieved through a careful reduction of scattering and absorption losses that we simulate, quantify and correlate to measurements. This advancement in waveguide resonator technology paves the way to all-waveguide Billion Q cavities for applications including nonlinear optics, atomic clocks, quantum photonics and high-capacity fiber communications.

Measurement-based care: Use of the Beck Anxiety Inventory (BAI) in a veteran population.

The Beck Anxiety Inventory (BAI) is widely used within the Veterans Health Administration (VHA), both as an assessment tool and as a part of measurement-based care practices. However, there is preliminary evidence that the BAI may perform uniquely in veteran samples, emphasizing the need for a comprehensive investigation of the BAI in this population. The present study compared the normative data reported by Beck and Steer (1993) to secondary data generated by a nationwide sample of U.S. military veterans receiving treatment through the VHA. Secondary data, including initial BAI scores, demographic characteristics, treatment location, and diagnoses originally recorded during the course of usual VHA care over a 5-year period for 57,088 individual veterans, were extracted through the VA Informatics and Computing Infrastructure. BAI scores were compared across samples and various veteran subgroups. Exploratory and confirmatory factor analyses were also conducted. Results revealed that the BAI performed similarly across veteran and normative samples. Male and older veterans were found to have lower BAI scores than their respective counterparts. Factor analyses indicated that a three-factor model best fit the veteran data. Additionally, a cut score of 18 best differentiated between veterans with and without anxiety and related disorders. This study helps support the use of the BAI as a reliable and valid instrument for assessing anxiety symptoms in veterans. Additional research is recommended to better guide BAI interpretation across age groups and sexes/genders. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Venoarterial ECMO for Adults: JACC Scientific Expert Panel.

Venoarterial extracorporeal membrane oxygenation (ECMO) is a rescue therapy that can stabilize patients with hemodynamic compromise, with or without respiratory failure, for days or weeks. In cardiology, the main indications for ECMO include cardiac arrest, cardiogenic shock, post-cardiotomy shock, refractory ventricular tachycardia, and acute management of complications of invasive procedures. The fundamental premise underlying ECMO is that it is a bridge-to recovery, to a more durable bridge, to definitive treatment, or to decision. As a very resource- and effort-intensive intervention, ECMO should not be used on unsalvageable patients. As the use of this technology continues to evolve rapidly, it is important to understand the indications and contraindications; the logistics of ECMO initiation, management, and weaning; the general infrastructure of the program (including the challenges associated with transferring patients supported by ECMO); and ethical considerations, areas of uncertainty, and future directions.

Evaluation of a Shortened South Oaks Gambling Screen in veterans with addictions.

Rates of pathological gambling have increased with the availability of legalized gambling. Substance-abuse units increasingly recognize the need to assess for gambling problems. The South Oaks Gambling Screen (SOGS; H. R. Lesieur & S. B. Blume, 1987) has filled this need. Previous research (M. Oehlert & K. Nelson, 2004) has considered the feasibility of reducing the length of the SOGS while maintaining its ability to identify people at risk for problematic gambling. In this study, the authors examined the utility of a shortened SOGS (SSOGS) in a 2nd sample of veterans with addictions. The authors used data analysis to explore SSOGS psychometric properties and to provide additional support for use of the shorter instrument.

The role of continuous fetal monitoring in the management of preterm premature rupture of membranes.

OBJECTIVE: Continuous fetal monitoring (CFM) is often used in the management of preterm premature rupture of membranes (PPROM) but there is little evidence to support this approach. The objective of this study was to evaluate the clinical outcome of PPROM when managed by CFM. METHODS: A retrospective review was conducted of 129 cases PPROM outcomes for the period January 1, 1998 to December 31, 2003. All women underwent CFM. Delivery was carried out for non-reassuring fetal testing, vaginal bleeding, evidence of infection, positive vaginal pool phosphatidylglycerol when available, and spontaneous labor. RESULTS: Delivery was carried out because of an abnormal fetal heart tracing in 15 women (11.7%). The mean gestational age at admission was 32.2 weeks (95% CI 31.7-32.7), the mean gestational age at delivery was 32.7 weeks (95% CI 32.2-33.1), and the mean latency period was 3.3 days (95% CI 1.5-5.0). Gestational age at rupture of membranes was inversely correlated with latency period (n = 128, r = -0.372, p < 0.001). With regard to gestational age, gravidity, and latency period there was no significant difference noted with respect to why the subjects delivered. No intrauterine deaths occurred in the study. CONCLUSION: In our series, fetal heart rate tracing abnormalities were the indication for delivery in a small but significant percentage of conservatively managed PPROM cases. Our review suggests that a prospective trial of CFM versus intermittent monitoring techniques should be carried out.

The effect of a 12-month longitudinal long-term care rotation on knowledge and attitudes of internal medicine residents about geriatrics.

OBJECTIVE: To determine if participation in a 12-month longitudinal long-term care (LTC) rotation resulted in improved knowledge and attitudes about geriatrics. DESIGN: Longitudinal study with paired measurements. SETTING: A community LTC facility and a university-affiliated, community-based internal medicine residency program. PARTICIPANTS: Sixty-seven internal medicine residents who participated in the rotation from 1997 through 2004. INTERVENTION: The internal medicine residents attended nursing home (NH) rounds one half day per month for 1 year, during which time they participated in a case-based interactive lecture on a core geriatric topic and rounded on their assigned patients. MEASUREMENTS: Knowledge was assessed using a 70-item test. Attitudes were evaluated with a 28-item, 5-point Likert scale (1 = least positive, 5 = most positive). RESULTS: The percent correct responses on geriatric knowledge pretest was 47% (95% CI = 45.2% to 48.8%) and on the posttest it was 57.5% (95% CI = 55.3% to 59.6%) (t = 8.180, df = 67, P < .001). The pretest total attitude score was 3.6 (95% CI = 3.6 to 3.7), with a posttest score of 3.7 (95% CI = 3.7 to 3.8) (P < .001). The difference in this total was accounted for mainly by the significant changes in the attitude subscales in educational preparation (pretest 3.6 [95% CI = 3.5 to 3.8]; posttest 3.8 [95% CI = 3.7 to 3.9] [P < .001]), general attitudes (pretest 4.0 [95% CI = 3.9 to 4.1]; posttest 4.2 [95% CI = 4.0 to 4.3] [P = .006]), and therapeutic potential (pretest 3.7 [95% CI = 3.5 to 3.8]; posttest 3.8 [95% CI = 3.7 to 3.9] [P = .048]). CONCLUSION: A longitudinal LTC rotation is an efficient and effective way to systematically provide internal medicine residents their core knowledge and experience in geriatrics.

Noncompetitive and Competitive Adsorption of Heavy Metals in Sulfur-Functionalized Ordered Mesoporous Carbon.

In this work, sulfur-functionalized ordered mesoporous carbons were synthesized by activating the soft-templated mesoporous carbons with sulfur bearing salts that simultaneously enhanced the surface area and introduced sulfur functionalities onto the parent carbon surface. XPS analysis showed that sulfur content within the mesoporous carbons were between 8.2% and 12.9%. The sulfur functionalities include C-S, C═S, -COS, and SOx. SEM images confirmed the ordered mesoporosity within the material. The BET surface areas of the sulfur-functionalized ordered mesoporous carbons range from 837 to 2865 m2/g with total pore volume of 0.71-2.3 cm3/g. The carbon with highest sulfur functionality was examined for aqueous phase adsorption of mercury (as HgCl2), lead (as Pb(NO3)2), cadmium (as CdCl2), and nickel (as NiCl2) ions in both noncompetitive and competitive mode. Under noncompetitive mode and at a pH greater than 7.0 the affinity of sulfur-functionalized carbons toward heavy metals were in the order of Hg > Pb > Cd > Ni. At lower pH, the adsorbent switched its affinity between Pb and Cd. In the noncompetitive mode, Hg and Pb adsorption showed a strong pH dependency whereas Cd and Ni adsorption did not demonstrate a significant influence of pH. The distribution coefficient for noncompetitive adsorption was in the range of 2448-4000 mL/g for Hg, 290-1990 mL/g for Pb, 550-560 mL/g for Cd, and 115-147 for Ni. The kinetics of adsorption suggested a pseudo-second-order model fits better than other models for all the metals. XPS analysis of metal-adsorption carbons suggested that 7-8% of the adsorbed Hg was converted to HgSO4, 14% and 2% of Pb was converted to PbSO4 and PbS/PbO, respectively, and 5% Cd was converted to CdSO4. Ni was below the detection limit for XPS. Overall results suggested these carbon materials might be useful for the separation of heavy metals.

Left ventricular assist device malfunction: a systematic approach to diagnosis.

OBJECTIVES: A protocol was designed to diagnose the common malfunctions of a left ventricular assist device (LVAD). BACKGROUND: Mechanical circulatory support, primarily with an LVAD, is increasingly used for treatment of advanced heart failure (HF). Left ventricular assist device dysfunction is a recognized complication; but heretofore, a systematic method to accurately diagnose LVAD dysfunction has not been thoroughly described. METHODS: We developed a catheter-based protocol designed to characterize a normally functioning LVAD and diagnose multiple types of dysfunction. A total of 15 studies of 10 patients supported with an LVAD were reviewed. All patients had been evaluated due to concerns regarding LVAD dysfunction. RESULTS: Of 15 examinations performed, 11 documented severe LVAD inflow valve regurgitation. One of these cases proved to have coexistent severe mitral valve regurgitation. One case was diagnosed with distortion of the LVAD outflow graft. One case of suspected embolization from the pumping chamber excluded the outflow graft as the source of emboli. One study had aortic insufficiency. CONCLUSIONS: As LVAD use for treatment of end-stage HF becomes widespread and durations of support are extended, dysfunction will be increasingly prevalent. This catheter-based protocol provided a practical method to diagnose multiple causes of LVAD dysfunction.

Perianal versus anorectal specimens: is there a difference in Group B streptococcal detection?

OBJECTIVE: To investigate whether specimens obtained from the perianal area have a Group B streptococcal culture detection rate similar to anorectal specimens. METHODS: This is a prospective cohort study at a tertiary care university-affiliated teaching hospital. A total of 136 pregnant women between 33 and 40 weeks' gestation were recruited. Three samples for Group B streptococcal culture detection were obtained from each subject in the following order: perianal sample, vaginoperianal sample, and an anorectal sample. The women were asked to rank their pain or discomfort with obtaining the anorectal sample. The vaginoperianal specimen is the standard sample obtained from antepartum patients in this clinic, and, therefore, it serves as the control. RESULTS: Of the 136 subjects, 26.5% of the control, vaginoperianal samples were positive for Group B streptococcal culture. In comparison, 27.2% of the anorectal specimens and 28.7% of the perianal specimens were positive for Group B streptococcal culture. There was no statistically significant difference in the detection of Group B streptococcal culture among the three sample sites. Evaluation of the pain experienced with an anorectal sampling showed that 68% of subjects ranked their pain between mild to moderate, and 5% noted severe pain. CONCLUSION: The Group B streptococcal detection rate was not different among the three sampling sites. Therefore, pregnant women do not need to be subjected to the additional pain of anorectal sampling to detect Group B Streptococcus.

Modeling unipolar depression as a chaotic process.

This study inspected the deterministic structure of unipolar depression. Two women self-monitored sadness hourly 10 times a day for 6 months. One woman had a recurrent history of unipolar depression, and the other did not. Data were analyzed by visual inspection, examination of the Fourier transforms of the time plots, and the correlation dimension. Results suggested that in addition to a strong periodic component that existed only within the depressed subject's mood time series, a low-dimensional chaotic process might have been operating. In the nondepressed control subject, no such periodicity or process could be identified. The findings support maladaptive deterministic theories of mood disorders and have implications for the assessment of unipolar depression.

Nursing education and implications for left ventricular assist device destination therapy.

The HeartMate VE Left Ventricular Assist Device (vented electric abdominally positioned pulsatile blood pump; Thoratec Corp., Pleasanton, CA), approved as a permanent support, or destination therapy, by the US Food and Drug Administration in 2002 and Medicare in 2003, is now a potential therapy for numerous patients. Postimplantation nursing care is crucial to the success of left ventricular support device therapy and long-term recipient outcome. Nurses also contribute to cost containment, making this a viable treatment for the facility and the patient. Consequently, nurses must be educated about left ventricular assist device concepts and challenges, the benefits of device placement, intensive care unit and postintensive care unit daily care requirements, and outpatient preparation. This knowledge will enable nurses to provide necessary care and to educate recipients, families, and community health care providers on how to give appropriate posthospital care.

The left ventricular assist device.

Of the 400,000 people in the United States who develop end-stage heart failure each year, 60,000 are unresponsive to medical therapy and 2,500 undergo heart transplantation. Surgically implanted pumps, called LVADs, are extending many lives.

Examining the performance of the brief addiction monitor.

The Center for Excellence in Drug Abuse Treatment and Education (Center for Excellence in Substance Abuse Treatment and Education (CESATE; 2010). Brief Addiction Monitor: Manual of Operations. Philadelphia, PA) recently suggested that Veterans Affairs' (VA) addictions treatment programs, in order to encourage measurement based care, begin using a new measure of substance abuse, the Brief Addictions Monitor (BAM). To date, only one study Caccolia et al, 2013. Development and initial evaluation of the Brief Addiction Monitor (BAM). Journal of Substance Abuse Treatment, 44, 256-63. doi: http://dx.doi.org/10.1016/j.jsat.2012.07.013) has examined the psychometric properties of a version of this instrument. However, this study did not use the version of the BAM currently available to most VA providers via the mental health assistant software; rather, the authors reported the properties of a BAM where most of the items had continuous (or near continuous) response options. The current study seeks to provide data on the version of the BAM which uses 5 point Likert scale response options for its questions, the version available on the mental health assistant software. Based on data from more than 700 veterans enrolled in out-patient (OP) and in-patient (IP) addictions treatment programs, this study examined the factor structure, reliability, and validity of this version of the BAM. Across both groups, results suggested that the BAM lacked a reliable factor structure, in contrast to the findings from the earlier study. However, a single scale, composed of a minority of items on the BAM, showed promise. A minority of the items (five) provided valid information across both OP and IP samples when applied individually, as indicated by convergent and divergent validity comparisons with other measures of functioning; tracking changes in functioning over the course of treatment; and correlating with changes in convergent and divergent validity measures. This partially supported the CESATE (CESATE; 2010). Brief Addiction Monitor: Manual of Operations. Philadelphia, PA) call to use the individual BAM items. Overall, results suggested that changing the structure of the response options may have had a negative impact on the psychometric properties of the BAM.