Major incident preparedness in a post pandemic world: A survey of anaesthetists

The COVID-19 pandemic profoundly changed anaesthetic and critical care departments across the UK and fulfilled the definition of a major incident for an extended period of time. It is regularly highlighted that individual and organisational readiness for major incident is inconsistent, as is support in the aftermath. Post-pandemic rates of anxiety and PTSD in healthcare staff have significantly increased, but we still have no embedded method of helping to prevent it. Clinical debriefing is an emerging tool with proven improved psychological outcomes for staff following an adverse event. We surveyed 354 anaesthetists of a range of grades and experiences prior to attending a webinar centred on major incident organisation, human factors and clinical debrief. While 73.8% knew where to access their hospital's major incident plan, only 16.8% had been trained in any form of clinical debrief. Only 29% had ever received any formal training in major incident management. It seems that the occurrence of major incidents is no longer a 'once in a career' event. The inconsistencies in training and preparedness shown in our survey highlight opportunities for our workforce to be more agile and subsequently better supported for the future.

Metabolomic profiling of wild rooibos (Aspalathus linearis) ecotypes and their antioxidant-derived phytopharmaceutical potential

INTRODUCTION

Aspalathus linearis (commonly known as rooibos) is endemic to the Cape Floristic Region of South Africa and is a popular herbal drink and skin phytotherapeutic ingredient, with health benefits derived primarily from its unique phenolic content. Several, seemingly habitat-specific ecotypes from the Cederberg (Western Cape) and Northern Cape have morphological, ecological, genetic and biochemical differences.

OBJECTIVES AND METHODS

Despite the commercial popularity of the cultivated variety, the uncultivated ecotypes are largely understudied. To address gaps in knowledge about the biochemical constituency, ultra-performance liquid chromatography-mass spectrometry analysis of fifteen populations was performed, enabling high-throughput metabolomic fingerprinting of 50% (v/v) methanolic extracts. Antioxidant screening of selected populations was performed via three assays and antimicrobial activity on two microbial species was assessed. The metabolomic results were corroborated with total phenolic and flavonoid screening of the extracts.

RESULTS AND DISCUSSION

Site-specific chemical lineages of rooibos ecotypes were confirmed via multivariate data analyses. Important features identified via PLS-DA disclosed higher relative abundances of certain tentative metabolites (e.g., rutin, aspalathin and apiin) present in the Dobbelaarskop, Blomfontein, Welbedacht and Eselbank sites, in comparison to other locations. Several unknown novel metabolites (e.g., m/z 155.0369, 231.0513, 443.1197, 695.2883) are responsible for metabolomic separation of the populations, four of which showed higher amounts of key metabolites and were thus selected for bioactivity analysis. The Welbedacht and Eselbank site 2 populations consistently displayed higher antioxidant activities, with 2,2-azino-bis (3-ethylbenzothiazoline-6-sulphonic acid) (ABTS) radical scavenging activities of 679.894 ± 3.427 µmol Trolox/g dry matter and 635.066 ± 5.140 µmol Trolox/g dry matter, respectively, in correlation with a high number of phenolic and flavonoid compounds. The contribution of the individual metabolites to the pharmacological effectiveness of rooibos remains unknown and as such, further structural elucidation and phytopharmacological testing is thus urgently needed.

The Effects of Clopidogrel Duration On Carotid Artery In-stent Restenosis

OBJECTIVE

There is limited data supporting a specific duration for dual antiplatelet therapy in carotid artery stenting (CAS), and most clinical evidence is derived from studies involving coronary interventions. As a result, the appropriate duration of dual antiplatelet therapy after CAS has yet to be determined. We aimed to elucidate whether the duration of dual antiplatelet therapy played a role in the rate of carotid in-stent restenosis.

METHODS

A retrospective analysis of all patients who underwent CAS at our institution over a 20-year period (1996-2016) was performed (n=279). Patients who did not complete their follow-up duplex studies or were not discharged on clopidogrel were excluded from the study. Patients were separated into short-term (<6 weeks, n=159) and long-term (>6 weeks, n=112) clopidogrel users based on duration of therapy. We defined clinically significant in-stent restenosis as >50% restenosis (PSV = 224 cm/s) in symptomatic patients and >80% restenosis (PSV = 325 cm/s) in asymptomatic patients status-post prior CAS based on published velocity criteria. Rates of in-stent restenosis at 1-year, 2-year, and 5-year intervals were analyzed between the two groups using chi-squared analysis.

RESULTS

Demographic information was largely similar between the two groups; however, short-term clopidogrel users were more likely to have a history of atrial fibrillation (9.43% vs. 1.68%, p=0.008) and were less likely to have a history of CABG (16.35% vs. 29.41%, p=0.009), diabetes (33.34% vs. 49.58%, p=0.006) and CAD (50.31% vs. 63.03%, p=0.035). All patients were on long-term aspirin therapy. There was no significant difference between overall rates of in-stent restenosis between the short-term and long-term clopidogrel users (5.03% vs. 9.24%, p=0.168) within 5 years of the index procedure. Similar results were observed when these groups were evaluated at 1-year (5.61 % vs. 3%, p=0.321), 2-year (2.02% vs. 6.59%, p=0.072), and 5-year (2.24% vs. 3.57%, p=0.635) follow-up.

CONCLUSION

No statistically significant difference was observed in the rate of in-stent restenosis after CAS between short-term and long-term clopidogrel therapy. Patients in whom there is no other indication for longer duration clopidogrel therapy may be considered for shorter duration course of dual antiplatelet therapy following CAS.

Indigenous Australians critically ill with sepsis: Characteristics, outcomes, and areas for improvement

BACKGROUND

Aboriginal and Torres Strait Islander Australians have amongst the highest incidence of sepsis globally.

OBJECTIVE

The objective of this study was to describe the characteristics, short- and long-term outcomes of non-Indigenous, Aboriginal Australian and Torres Strait Islander Australians admitted with sepsis to an intensive care unit (ICU) to inform healthcare outcome improvement.

METHODS

A retrospective cohort study of 500 consecutive sepsis admissions to the Cairns Hospital ICU compared clinical characteristics, short-term (before ICU discharge) and long-term (2000 days posthospital discharge) outcomes. Cohort stratification was done by voluntary disclosure of Indigenous status.

RESULTS

Of the 442 individual admissions, 145 (33%) identified as Indigenous Australian. Indigenous and non-Indigenous Australians had similar admission Acute Physiology and Chronic Health Evaluation-3 scores (median [interquartile range]: 70 [52-87] vs. 69 [53-87], P = 0.87), but Indigenous patients were younger (53 [43-60] vs. 62 [52-73] years, P < 0.001) and were more likely to have chronic comorbidities such as type 2 diabetes (58% vs. 23%, P < 0.001), cardiovascular disease (40% vs 28%, P = 0.01), and renal disease (39% vs. 10%, P < 0.001). They also had more hazardous healthcare behaviours such as smoking (61% vs. 45%, P = 0.002) and excess alcohol consumption (40% vs. 18%, P < 0.001). Despite this, the case-fatality rate of Indigenous and non-Indigenous Australians before ICU discharge (13% vs. 12%, P = 0.75) and 2000 days post hospital discharge (25 % vs. 28 %, P = 0.40) was similar. Crucially, however, Indigenous Australians died younger both in the ICU (median [interquartile range] 54 (50-60) vs. 70 [61-76], P < 0.0001) and 2000 days post hospital discharge (58 [53-63] vs. 70 [63-77] years, P < 0.0001).

CONCLUSIONS

Although Indigenous Australians critically ill with sepsis have similar short and long-term mortality rates, they present to hospital, die in-hospital, and die post-discharge significantly younger. Unique cohort characteristics may explain these outcomes, and assist clinicians, researchers and policy-makers in targeting interventions to these characteristics to best reduce the burden of sepsis in this cohort and improve their healthcare outcomes.

Coronavirus Disease 2019 Vaccination Is Associated With Reduced Outpatient Antibiotic Prescribing in Older Adults With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2: A Population-Wide Cohort Study

BACKGROUND

Antibiotics are frequently prescribed unnecessarily in outpatients with coronavirus disease 2019 (COVID-19). We sought to evaluate factors associated with antibiotic prescribing in outpatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

METHODS

We performed a population-wide cohort study of outpatients aged ≥66 years with polymerase chain reaction-confirmed SARS-CoV-2 from 1 January 2020 to 31 December 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1 week before (prediagnosis) and 1 week after (postdiagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary-series COVID-19 vaccination, in univariate and multivariable analyses.

RESULTS

We identified 13 529 eligible nursing home residents and 50 885 eligible community-dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3020 (22%) and 6372 (13%), respectively, received at least 1 antibiotic prescription within 1 week of a SARS-CoV-2 positive result. Antibiotic prescribing in nursing home and community residents occurred, respectively, at 15.0 and 10.5 prescriptions per 1000 person-days prediagnosis and 20.9 and 9.8 per 1000 person-days postdiagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted postdiagnosis incidence rate ratios (95% confidence interval) of 0.7 (0.4-1) and 0.3 (0.3-0.4), respectively.

CONCLUSIONS

Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis but was reduced in COVID-19-vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.

Frequency-Dependent Squeezed Vacuum Source for the Advanced Virgo Gravitational-Wave Detector

In this Letter, we present the design and performance of the frequency-dependent squeezed vacuum source that will be used for the broadband quantum noise reduction of the Advanced Virgo Plus gravitational-wave detector in the upcoming observation run. The frequency-dependent squeezed field is generated by a phase rotation of a frequency-independent squeezed state through a 285 m long, high-finesse, near-detuned optical resonator. With about 8.5 dB of generated squeezing, up to 5.6 dB of quantum noise suppression has been measured at high frequency while close to the filter cavity resonance frequency, the intracavity losses limit this value to about 2 dB. Frequency-dependent squeezing is produced with a rotation frequency stability of about 6 Hz rms, which is maintained over the long term. The achieved results fulfill the frequency dependent squeezed vacuum source requirements for Advanced Virgo Plus. With the current squeezing source, considering also the estimated squeezing degradation induced by the interferometer, we expect a reduction of the quantum shot noise and radiation pressure noise of up to 4.5 dB and 2 dB, respectively.

Safety Concerns for Laboratory Professionals in Rural Practice Settings During Covid-19

Introduction/Objective

The COVID-19 pandemic exacerbated the health risks of laboratory professionals. This study aimed to understand the impact increased workload and decreased staffing levels have, specifically in rural areas where clinical laboratory testing is performed, and to document how these changes affect the wellbeing of laboratory professionals.

Methods/Case Report

The study integrated responses from a cross-sectional study of laboratory professionals which employed an anonymous electronic survey deployed between November of 2021 and February of 2022. Specific items asked if participants had worked in clinical laboratories since the public health emergency started, if they were concerned regarding Covid-19 transmission, adequate staffing, and support at their workplace. A subsequent qualitative study including focus groups and an interview questionnaire targeted laboratory professionals working in rural laboratories in four states of the Mid-west to further understand any immediate health impacts on wellbeing for these professionals.

Results (if a Case Study enter NA)

Among 438 participants in the survey that indicated they worked in the laboratory since March of 2020, 20% said they worked in non-metro US counties (RUCC 4-9). Among the non-metro laboratory professionals, 70% indicated that staffing levels in their laboratories were inadequate, with over 50% of them expressing concern about contracting Covid-19 at their workplace, and 53% saying they had been told to work despite a possible or confirmed exposure to the virus. The analysis of thirteen focus groups (N=59) and qualitative written interviews (n=15) found that workplace changes impacted the health of laboratory professionals in rural areas. These included lack of availability of laboratory equipment and increased work hours, which increased self-reported levels of stress. Recommendations for improvement included flexibility in scheduling of hours and proper compensation for overtime work.

Conclusion

Working in rural clinical laboratories during the Covid-19 pandemic exposed laboratory professionals to stress that was exacerbated by a work environment operating in scarcity.

Endospores associated with deep seabed geofluid features in the eastern Gulf of Mexico

Recent studies have reported up to 1.9 × 10²⁹ bacterial endospores in the upper kilometre of deep subseafloor marine sediments, however, little is understood about their origin and dispersal. In cold ocean environments, the presence of thermospores (endospores produced by thermophilic bacteria) suggests that distribution is governed by passive migration from warm anoxic sources possibly facilitated by geofluid flow, such as advective hydrocarbon seepage sourced from petroleum deposits deeper in the subsurface. This study assesses this hypothesis by measuring endospore abundance and distribution across 60 sites in Eastern Gulf of Mexico (EGM) sediments using a combination of the endospore biomarker 2,6-pyridine dicarboxylic acid or 'dipicolinic acid' (DPA), sequencing 16S rRNA genes of thermospores germinated in 50°C sediment incubations, petroleum geochemistry in the sediments and acoustic seabed data from sub-bottom profiling. High endospore abundance is associated with geologically active conduit features (mud volcanoes, pockmarks, escarpments and fault systems), consistent with subsurface fluid flow dispersing endospores from deep warm sources up into the cold ocean. Thermospores identified at conduit sites were most closely related to bacteria associated with the deep biosphere habitats including hydrocarbon systems. The high endospore abundance at geological seep features demonstrated here suggests that recalcitrant endospores and their chemical components (such as DPA) can be used in concert with geochemical and geophysical analyses to locate discharging seafloor features. This multiproxy approach can be used to better understand patterns of advective fluid flow in regions with complex geology like the EGM basin.

Compositional Constraints are Vital for Atmospheric PM2.5 Source Attribution over India

India experiences some of the highest levels of ambient PM_2.5 aerosol pollution in the world. However, due to the historical dearth of in situ measurements, chemical transport models that are often used to estimate PM_2.5 exposure over the region are rarely evaluated. Here, we conduct a novel model comparison with speciated airborne measurements of fine aerosol, revealing large biases in the ammonium and nitrate simulations. To address this, we incorporate process-level changes to the model and use satellite observations from the Cross-track Infrared Sounder (CrIS) and the TROPOspheric Monitoring Instrument (TROPOMI) to constrain ammonia and nitrogen oxide emissions. The resulting simulation demonstrates significantly lower bias (NMB_Modified: 0.19; NMB_Base: 0.61) when validated against the airborne aerosol measurements, particularly for the nitrate (NMB_Modified: 0.08; NMB_Base: 1.64) and ammonium simulation (NMB_Modified: 0.49; NMB_Base: 0.90). We use this validated simulation to estimate a population-weighted annual PM_2.5 exposure of 61.4 μg m^-3, with the RCO (residential, commercial, and other) and energy sectors contributing 21% and 19%, respectively, resulting in an estimated 961,000 annual PM_2.5-attributable deaths. Regional exposure and sectoral source contributions differ meaningfully in the improved simulation (compared to the baseline simulation). Our work highlights the critical role of speciated observational constraints in developing accurate model-based PM_2.5 aerosol source attribution for health assessments and air quality management in India.

Testing the effect of oxytocin on social grooming in bonobos

Oxytocin has attracted research attention due to its role in promoting social bonding. In bonobos and chimpanzees, the two species most closely related to humans, urinary oxytocin is known to correlate with key behaviours related to social bonding such as social grooming in chimpanzees and female-female sexual behaviour in bonobos. However, no study has demonstrated that the administration of oxytocin promotes real-life social interactions in Pan, leaving it unclear whether oxytocin is merely correlated with social behaviors or does affect them in these species. To test this, we administered nebulized oxytocin or saline placebo to a group of female bonobos and subsequently observed changes in their gross behavior during free interaction. We found an overall effect of more frequent grooming in the oxytocin condition. However, on the individual level this effect remained significant for only one participant in our follow-up models, suggesting future work should explore interindividual variation. Our results provide some experimental support for the biobehavioural feedback loop hypothesis, which posits that some functions of the oxytocin system support the formation and maintenance of social bonds through a positive feedback loop; however, further tests with a larger number of individuals are required. Our results, at a minimum, demonstrated that oxytocin affects spontaneous, naturalistic social interactions of at least some female bonobos, adding to accumulating evidence that oxytocin modulates complex social behaviors of Pan.

Scalable radiotherapy data curation infrastructure for deep-learning based autosegmentation of organs-at-risk: A case study in head and neck cancer

In this era of patient-centered, outcomes-driven and adaptive radiotherapy, deep learning is now being successfully applied to tackle imaging-related workflow bottlenecks such as autosegmentation and dose planning. These applications typically require supervised learning approaches enabled by relatively large, curated radiotherapy datasets which are highly reflective of the contemporary standard of care. However, little has been previously published describing technical infrastructure, recommendations, methods or standards for radiotherapy dataset curation in a holistic fashion. Our radiation oncology department has recently embarked on a large-scale project in partnership with an external partner to develop deep-learning-based tools to assist with our radiotherapy workflow, beginning with autosegmentation of organs-at-risk. This project will require thousands of carefully curated radiotherapy datasets comprising all body sites we routinely treat with radiotherapy. Given such a large project scope, we have approached the need for dataset curation rigorously, with an aim towards building infrastructure that is compatible with efficiency, automation and scalability. Focusing on our first use-case pertaining to head and neck cancer, we describe our developed infrastructure and novel methods applied to radiotherapy dataset curation, inclusive of personnel and workflow organization, dataset selection, expert organ-at-risk segmentation, quality assurance, patient de-identification, data archival and transfer. Over the course of approximately 13 months, our expert multidisciplinary team generated 490 curated head and neck radiotherapy datasets. This task required approximately 6000 human-expert hours in total (not including planning and infrastructure development time). This infrastructure continues to evolve and will support ongoing and future project efforts.

Diagnostic accuracy of magnetic resonance imaging for nerve injury in obstetric brachial plexus injury: protocol for systematic review and meta-analysis

BACKGROUND

Early and accurate clinical diagnosis of the extent of obstetric brachial plexus injury (OBPI) is challenging. The current gold standard for delineating the nerve injury is surgical exploration, and synchronous reconstruction is performed if indicated. Magnetic resonance imaging (MRI) is a non-invasive method of assessing the anatomy and severity of nerve injury in OBPI but the diagnostic accuracy is unclear. The primary objective of this review is to determine the diagnostic accuracy of MRI in comparison to surgical brachial plexus exploration for detecting root avulsion in children under 5 with OBPI. The secondary objectives are to determine its' diagnostic accuracy for detecting nerve abnormality and detecting pseudomeningocele(s) in this group.

METHODS

This review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).We will include studies reporting the accuracy of MRI (index test) compared to surgical exploration (reference standard) in detecting any of the three target conditions (root avulsion, any nerve abnormality and pseudomeningocele) in children under five with OBPI. Case reports and studies where the number of true positives, false positives, true negatives and false negatives cannot be derived will be excluded. We plan to search PubMed, Embase and CENTRAL for relevant studies from database inception to 15 June 2022. We will also search grey literature (medRxiv, bioRxiv and Google Scholar) and perform forward and backward citation chasing. Screening and full-text assessment of eligibility will be conducted by two independent reviewers, who will then both extract the relevant data. The QUADAS-2 tool will be used to assess methodological quality and risk of bias of included studies by two reviewers independently. The following test characteristics for the target conditions will be extracted: true positives, false positives, true negatives and false negatives. Estimates of sensitivity and specificity with 95% confidence intervals will be shown in forest plots for each study. If appropriate, summary sensitivities and specificities for target conditions will be obtained via meta-analyses using a bivariate model.

DISCUSSION

This study will aim to clarify the diagnostic accuracy of MRI for detecting nerve injury in OBPI and define its clinical role.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021267629.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Oxytocin promotes species-relevant outgroup attention in bonobos and chimpanzees

Previous research has found that oxytocin (OT) is associated with intergroup behaviour in humans as well as wild chimpanzees, and that exogenous OT affects Pan social attention. The two Pan species, bonobos and chimpanzees, differ drastically from one another in their intensity of intergroup competition, with lethal intergroup aggression often led by males in chimpanzees and more tolerant associations often centered around females in bonobos. However, it remains unclear how exogenous OT changes the two species' responses to ingroup and outgroup individuals. In this study, after intranasal administration of nebulized OT or placebo control, chimpanzees and bonobos viewed image pairs of ingroup and outgroup conspecifics while their eye movements were tracked with an eye-tracker. Although the overall effect of OT was small, we found that OT shifted bonobos' and chimpanzees' attention to outgroup images of the sex primarily involved in intergroup encounters in each species. Specifically, OT selectively shifted attention towards outgroup photos of female conspecifics in bonobos, and those of outgroup male conspecifics in chimpanzees. This suggests that OT generally promotes outgroup attention in both bonobos and chimpanzees but this effect is restricted to the sex most relevant in intergroup relations. These results suggest that, although OT may have a generally conserved role in hominid intergroup behaviour, it may act in species-relevant ways under the influence of their socio-ecological backgrounds.

AB1568-PARE LIVED EXPERIENCES OF POSTMENOPAUSAL OMANI WOMEN WITH OSTEOPOROSIS

Background

Osteoporosis is a globally significant clinical public health problem associated with age-related fractures [1,2]. Most research on the impact of the disease has been based on quantitative survey data. There are relatively few qualitative studies exploring women’s lived experience with osteoporosis. Furthermore, most data are from Western countries, with no data from the Middle East. Direct access to lived experiences is a powerful tool for gaining insights into a disease [3]. This study aimed to determine the lived experience of postmenopausal Omani women with osteoporosis.

Objectives

This study sought to answer three questions:

1.What does living with osteoporosis mean for postmenopausal Omani women?

2.How does culture impact the lives of postmenopausal Omani women with osteoporosis?

3.How do postmenopausal Omani women with osteoporosis perceive the support and care provided by healthcare professionals?

Methods

An interpretive phenomenology design was used with a purposive sample of 15 postmenopausal Omani women with osteoporosis and fragility fractures from primary and secondary care facilities in Muscat, Oman. Audio recorded, semi-structured, one-on-one interviews were held by Zoom and telephone; Crist and Tanner’s framework was used to analyze data and identify key themes.

Results

The mean age of the participants was 63 years. Five (33.3%) reported a previous fracture. Just over half (53%) were illiterate; three (20%) had studied in college. Key themes related to their lived experience emerged from the data analysis: culture and religion; health care professionals’ attitudes; and services and treatment regimen. The subjects’ social and cultural lives were negatively impacted by osteoporosis and fragility fractures, which prevented some from attending celebrations such as close family marriages and religious gatherings. Participants played significant care-giving roles as wives, mothers and grandmothers but many were unable to perform many household chores, such as cooking, due to the osteoporosis and fractures. They perceived healthcare professionals through the professionals’ communication styles and information they provided. Participants satisfied with their doctor’s communication style described it as humanistic, with humour added, noting they provide health information and understand patients’ needs. Those not satisfied indicated their doctors had poor communication styles, showed insufficient interest in them, and asked few questions during their appointments. Professionals at in-patient clinics were perceived as more caring and empathetic than those at out-patient clinics. Treatment abroad was preferred by these women, though some were highly satisfied with their treatment from Omani hospitals. Beliefs about and usage of traditional herbal remedies for the management of fragility fractures differed between educated and non-educated women.

Conclusion

This study explored postmenopausal Omani women’s experiences of living with osteoporosis and fragility fractures including the impact of the disease on social and cultural life. It contributes also to our understanding of the experience of the disease in non-western settings.

References

[1]Barake M, El Eid R, Chakhtoura M, Meho L, Mahmoud T, Atieh J, et al. Osteoporotic hip and vertebral fractures in the Arab region: a systematic review. Osteoporosis International [Internet]. 2021. Available from: https://doi.org/10.1007/s00198-021-05937-z

[2]Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporosis International. 2013; 24:23-57.

[3]McIntosh I, Wright, S. Exploring what the notion of ‘lived experience’ offers for social policy analyses. J Soc Policy. 2018;48(3):449-67.

Disclosure of Interests

None declared

Characterization of Healthcare-Associated and Community-Associated Clostridioides difficile Infections among Adults, Canada, 2015-2019

We investigated epidemiologic and molecular characteristics of healthcare-associated (HA) and community-associated (CA) Clostridioides difficile infection (CDI) among adult patients in Canadian Nosocomial Infection Surveillance Program hospitals during 2015–2019. The study encompassed 18,455 CDI cases, 13,735 (74.4%) HA and 4,720 (25.6%) CA. During 2015–2019, HA CDI rates decreased by 23.8%, whereas CA decreased by 18.8%. HA CDI was significantly associated with increased 30-day all-cause mortality as compared with CA CDI (p<0.01). Of 2,506 isolates analyzed, the most common ribotypes (RTs) were RT027, RT106, RT014, and RT020. RT027 was more often associated with CDI-attributable death than was non-RT027, regardless of acquisition type. Overall resistance C. difficile rates were similar for all drugs tested except moxifloxacin. Adult HA and CA CDI rates have declined, coinciding with changes in prevalence of RT027 and RT106. Infection prevention and control and continued national surveillance are integral to clarifying CDI epidemiology, investigation, and control.

Resprouters Versus Reseeders: Are Wild Rooibos Ecotypes Genetically Distinct?

Aspalathus linearis (Burm. F.) R. Dahlgren (Fabaceae) or rooibos, is a strict endemic species, limited to areas of the Cederberg (Western Cape) and the southern Bokkeveld plateau (Northern Cape) in the greater Cape Floristic Region (CFR) of South Africa. Wild rooibos, unlike the cultivated type, is variable in morphology, biochemistry, ecology and genetics, and these ecotypes are broadly distinguished into two main groups, namely, reseeders and resprouters, based on their fire-survival strategy. No previous assessment of genetic diversity or population structure using microsatellite markers has been conducted in A. linearis. This study aimed to test the hypothesis that wild rooibos ecotypes are distinct in genetic variability and that the ecotypes found in the Northern Cape are differentiated from those in the Cederberg that may be linked to a fire-survival strategy as well as distinct morphological and phytochemical differences. A phylogeographical and population genetic analyses of both chloroplast (trnLF intergenic region) and newly developed species-specific nuclear markers (microsatellites) was performed on six geographically representative wild rooibos populations. From the diversity indices, it was evident that the wild rooibos populations have low-to-moderate genetic diversity (He: 0.618-0.723; Ho: 0.528-0.704). The Jamaka population (Cederberg, Western Cape) had the lowest haplotype diversity (H = 0.286), and the lowest nucleotide diversity (π = 0.006) even though the data revealed large variations in haplotype diversity (h = 0.286-0.900) and nucleotide diversity (π = 0.006-0.025) between populations and amongst regions where wild rooibos populations are found. Our data suggests that populations of rooibos become less diverse from the Melkkraal population (Suid Bokkeveld, Northern Cape) down towards the Cederberg (Western Cape) populations, possibly indicative of clinal variation. The largest genetic differentiation was between Heuningvlei (Cederberg, Western Cape) and Jamaka (FST = 0.101) localities within the Cederberg mountainous region, and, Blomfontein (Northern Cape) and Jamaka (Cederberg) (FST = 0.101). There was also a significant isolation by distance (R2 = 0.296, p = 0.044). The presence of three main clusters is also clearly reflected in the discriminant analysis of principal components (DAPC) based on the microsatellite marker analyses. The correct and appropriate management of wild genetic resources of the species is urgently needed, considering that the wild Cederberg populations are genetically distinct from the wild Northern Cape plants and are delineated in accordance with ecological functional traits of reseeding or resprouting, respectively. The haplotype divergence of the ecotypes has also provided insights into the genetic history of these populations and highlighted the need for the establishment of appropriate conservation strategies for the protection of wild ecotypes.

The founder sociality hypothesis

In this review, we propose that the social dynamics of founder populations in novel and newly available environments can have critical effects in shaping species' sociality and can produce long-lasting changes in social structure and behavior. For founder populations which expand into an underexploited niche separated from the parent population, the necessity of bond formation with strangers, lack of clear territories, and initial abundance of resources can lead to altered initial social dynamics to which subsequent generations adapt. We call this the founder sociality hypothesis. After specifying the theoretical reasoning and mechanism of effect, we focus on three particular cases where the social dynamics of founder populations may have a central role in explaining their modern behavioral ecology. In particular, we develop and review evidence for three predictions of the founder sociality hypothesis in territorial, mixed-sex group forming species: relatively stronger social bonds in the dispersing sex with relatively weaker bonds in the nondispersing sex, reduced territoriality, and increased social tolerance. We briefly touch on the implications for human evolution given our species' evolutionary history marked by frequent expansion and adaptation to novel environments. We conclude by proposing several experiments and models with testable predictions following from the founder sociality hypothesis.

The Impact of Transparency and Decision Risk on Human-Automation Teaming Outcomes

OBJECTIVE

Examine the effects of decision risk and automation transparency on the accuracy and timeliness of operator decisions, automation verification rates, and subjective workload.

BACKGROUND

Decision aids typically benefit performance, but can provide incorrect advice due to contextual factors, creating the potential for automation disuse or misuse. Decision aids can reduce an operator's manual problem evaluation, and it can also be strategic for operators to minimize verifying automated advice in order to manage workload.

METHOD

Participants assigned the optimal unmanned vehicle to complete missions. A decision aid provided advice but was not always reliable. Two levels of decision aid transparency were manipulated between participants. The risk associated with each decision was manipulated using a financial incentive scheme. Participants could use a calculator to verify automated advice; however, this resulted in a financial penalty.

RESULTS

For high- compared with low-risk decisions, participants were more likely to reject incorrect automated advice and were more likely to verify automation and reported higher workload. Increased transparency did not lead to more accurate decisions and did not impact workload but decreased automation verification and eliminated the increased decision time associated with high decision risk.

CONCLUSION

Increased automation transparency was beneficial in that it decreased automation verification and decreased decision time. The increased workload and automation verification for high-risk missions is not necessarily problematic given the improved automation correct rejection rate.

APPLICATION

The findings have potential application to the design of interfaces to improve human-automation teaming, and for anticipating the impact of decision risk on operator behavior.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Knowledge-based enrichment: Development of a novel enrichment device for captive chimpanzees

The field of environmental enrichment has grown considerably, but most enrichment is still focused on tasks where highly valued food rewards are directly visible. We designed a device which would instead make use of knowledge states, motivational structure, and physical reasoning skills and could use hidden, low-quality food items while remaining low in cost. Food items were hidden in small cardboard tubes and placed snugly inside another, larger, tube such that they were difficult to extract and presented a challenging dexterity and physical reasoning task. Rare favored food items were distributed so animals would be rewarded at irregular intervals. The devices were then presented to two groups of chimpanzees (Pan troglodytes) who either had experience extracting food from identical small cardboard tubes or had no such experience. We found that the chimpanzees with no prior experience with the small tubes used the device very little until one individual removed a small tube, revealing the food inside, at which point use time significantly increased. In the knowledgeable group, no change was observed after the first tube retrieval. Individuals in both groups used the devices for over 20 min each on average over a 1-h observation period, and in both facilities at least one device still contained all inner tubes. Our study suggests that enrichment can make use of animals' prior knowledge, that enrichment devices can thus be layered into one another, and reiterates the importance of considering animals' psychology in designing enrichment.

Suicidality in women with Premenstrual Dysphoric Disorder: a systematic literature review

Previous research has identified how menstruation is an important factor in both attempted and completed suicides for women. The purpose of this review was to outline (a) the risk profile for suicidality in women who were identified to experience Premenstrual Dysphoric Disorder (PMDD), a condition characterized by severe physical and psychological changes that occur during the luteal menstrual phase, and (b) the implications of these findings for clinical practice. A systematic literature review was conducted using five databases to identify any peer-reviewed articles published between 1989 and 2019. Ten papers eligible for inclusion were identified: three pertaining to suicide cognitions, five to suicide attempts and two to both cognitions and attempts. Findings showed that suicidal thoughts, ideation, plans and attempts were strongly associated with experiences of PMDD and that these findings were independent of psychiatric co-morbidities. However, women with PMDD did not present with more severe risk profiles for suicide attempts (in terms of frequency, impulsivity and lethality) or make more frequent attempts during the luteal menstrual phase compared with suicide attempters without PMDD. Women with PMDD should be considered a high risk group for suicidality; thus, identifying and treating symptoms are vital in reducing suicide attempts. Implications for clinical practice are outlined in the discussion.

Divergent effects of oxytocin on eye contact in bonobos and chimpanzees

Oxytocin has drawn significant research attention for its role in modulating mammalian social behavior. Despite generally conserved roles, oxytocin can function differently even in closely related species. Previous studies have shown that bonobos and chimpanzees, humans' two closest relatives, demonstrate considerable behavioral differences, including that bonobos look more at others' eyes than chimpanzees. Oxytocin is known to increase attention to another's eyes in many mammalian species (e.g. dogs, monkeys, and humans), yet this effect has not been tested in any nonhuman great ape species. This study examined how intranasally-administered oxytocin affects eye contact in bonobos and chimpanzees using eye tracking. Following administration of either oxytocin or saline control with a nebulizer, chimpanzees (n = 6) and bonobos (n = 5) were shown images of conspecific faces while their eye movement was recorded. Oxytocin changed the eye-looking behavior of bonobos and chimpanzees differently. We found that oxytocin increased eye contact in bonobos but not chimpanzees; while one chimpanzee showed an increase, interestingly, 5 out of 6 chimpanzees showed decreased looking to the eyes compared to the mouth, suggesting moderate eye avoidance. Given the importance of eye contact in their social interactions, our results suggest that oxytocin may play modulatory roles in bonobos' and chimpanzees' species-specific social behavior and underscore the importance of oxytocin in hominid social evolution.

The 4-Hour Cairns Sepsis Model: A novel approach to predicting sepsis mortality at intensive care unit admission

BACKGROUND

Sepsis commonly causes intensive care unit (ICU) mortality, yet early identification of adults with sepsis at risk of dying in the ICU remains a challenge.

OBJECTIVE

The aim of the study was to derive a mortality prediction model (MPM) to assist ICU clinicians and researchers as a clinical decision support tool for adults with sepsis within 4 h of ICU admission.

METHODS

A cohort study was performed using 500 consecutive admissions between 2014 and 2018 to an Australian tertiary ICU, who were aged ≥18 years and had sepsis. A total of 106 independent variables were assessed against ICU episode-of-care mortality. Multivariable backward stepwise logistic regression derived an MPM, which was assessed on discrimination, calibration, fit, sensitivity, specificity, and predictive values and bootstrapped.

RESULTS

The average cohort age was 58 years, the Acute Physiology and Chronic Health Evaluation III-j severity score was 72, and the case fatality rate was 12%. The 4-Hour Cairns Sepsis Model (CSM-4) consists of age, history of renal disease, number of vasopressors, Glasgow Coma Scale, lactate, bicarbonate, aspartate aminotransferase, lactate dehydrogenase, albumin, and magnesium with an area under the receiver operating characteristic curve of 0.90 (95% confidence interval = 0.84-0.95, p < 0.00001), a Nagelkerke R² of 0.51, specificity of 0.94, a negative predictive value of 0.98, and almost identical odds ratios during bootstrapping. The CSM-4 outperformed existing MPMs tested on our data set. The CSM-4 also performed similar to existing MPMs in their derivation papers whilst using fewer, routinely collected, and inexpensive variables.

CONCLUSIONS

The CSM-4 is a newly derived MPM for adults with sepsis at ICU admission. It displays excellent discrimination, calibration, fit, specificity, negative predictive value, and bootstrapping values whilst being easy to use and inexpensive. External validation is required.

Regulatory network analysis of Paneth cell and goblet cell enriched gut organoids using transcriptomics approaches

The epithelial lining of the small intestine consists of multiple cell types, including Paneth cells and goblet cells, that work in cohort to maintain gut health. 3D in vitro cultures of human primary epithelial cells, called organoids, have become a key model to study the functions of Paneth cells and goblet cells in normal and diseased conditions. Advances in these models include the ability to skew differentiation to particular lineages, providing a useful tool to study cell type specific function/dysfunction in the context of the epithelium. Here, we use comprehensive profiling of mRNA, microRNA and long non-coding RNA expression to confirm that Paneth cell and goblet cell enrichment of murine small intestinal organoids (enteroids) establishes a physiologically accurate model. We employ network analysis to infer the regulatory landscape altered by skewing differentiation, and using knowledge of cell type specific markers, we predict key regulators of cell type specific functions: Cebpa, Jun, Nr1d1 and Rxra specific to Paneth cells, Gfi1b and Myc specific for goblet cells and Ets1, Nr3c1 and Vdr shared between them. Links identified between these regulators and cellular phenotypes of inflammatory bowel disease (IBD) suggest that global regulatory rewiring during or after differentiation of Paneth cells and goblet cells could contribute to IBD aetiology. Future application of cell type enriched enteroids combined with the presented computational workflow can be used to disentangle multifactorial mechanisms of these cell types and propose regulators whose pharmacological targeting could be advantageous in treating IBD patients with Crohn's disease or ulcerative colitis.

Dog Stick Chewing: An Overlooked Instance of Tool Use?

Tool use is a central topic in research on cognitive evolution and behavioral ecology in non-human animals. Originally thought to be a uniquely human phenomenon, many other species have been observed making and using tools for a variety of purposes, starting with Goodall's (1964) groundbreaking work with chimpanzees in Gombe. Despite the frequent attention and great research interest in animal tool use, and ubiquity of the behavior, we argue here that chewing sticks by dogs (and other animals) should be included as a case of tool use. We discuss alternate possible explanations and then propose several testable predictions regarding this hypothesis. We suggest that tool use may be more common than is often assumed and that many cases of animal tool use may be overlooked.

Effect of automation transparency in the management of multiple unmanned vehicles

Automated decision aids can undoubtedly benefit system performance, but have the potential to provide incorrect advice, creating the possibility for automation disuse or misuse. This paper examined the extent to which increased automation transparency could improve the accuracy of automation use in a simulation of unmanned vehicle control. Participants were required to assign the best unmanned vehicle to complete missions. An automated recommender system provided advice but was not always reliable. Three levels of automation transparency were manipulated between-participants. Providing transparency regarding the reasoning underlying automated recommendations improved the accuracy of automation use, with no cost to decision time or subjective workload. Higher transparency in the form of projected decision outcome visualizations led to faster decisions, but less accurate automation use and an automation bias. Implications for the design of transparent interfaces to improve human-autonomy teaming outcomes in time-pressured environments are discussed.

The Evolution of Primate Short-Term Memory

Short-term memory is implicated in a range of cognitive abilities and is critical for understanding primate cognitive evolution. To investigate the effects of phylogeny, ecology and sociality on short-term memory, we tested the largest and most diverse primate sample to date (421 non-human primates across 41 species) in an experimental delayed-response task. Our results confirm previous findings that longer delays decrease memory performance across species and taxa. Our analyses demonstrate a considerable contribution of phylogeny over ecological and social factors on the distribution of short-term memory performance in primates; closely related species had more similar short-term memory abilities. Overall, individuals in the branch of Hominoidea performed better compared to Cercopithecoidea, who in turn performed above Platyrrhini and Strepsirrhini. Interdependencies between phylogeny and socioecology of a given species presented an obstacle to disentangling the effects of each of these factors on the evolution of short-term memory capacity. However, this study offers an important step forward in understanding the interspecies and individual variation in short-term memory ability by providing the first phylogenetic reconstruction of this trait’s evolutionary history. The dataset constitutes a unique resource for studying the evolution of primate cognition and the role of short-term memory in other cognitive abilities.

Quantum Backaction on kg-Scale Mirrors: Observation of Radiation Pressure Noise in the Advanced Virgo Detector

The quantum radiation pressure and the quantum shot noise in laser-interferometric gravitational wave detectors constitute a macroscopic manifestation of the Heisenberg inequality. If quantum shot noise can be easily observed, the observation of quantum radiation pressure noise has been elusive, so far, due to the technical noise competing with quantum effects. Here, we discuss the evidence of quantum radiation pressure noise in the Advanced Virgo gravitational wave detector. In our experiment, we inject squeezed vacuum states of light into the interferometer in order to manipulate the quantum backaction on the 42 kg mirrors and observe the corresponding quantum noise driven displacement at frequencies between 30 and 70 Hz. The experimental data, obtained in various interferometer configurations, is tested against the Advanced Virgo detector quantum noise model which confirmed the measured magnitude of quantum radiation pressure noise.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.

Single Center Outcomes of Carotid Artery Stenting in Veterans with Prior Head and Neck Cancer

BACKGROUND

Patients meeting criteria for intervention of carotid stenosis with a history of prior cervical radiation or neck dissection are considered "high risk" for carotid endarterectomy. This is a well-established indication for carotid artery stenting (CAS). The long-term outcomes of CAS in this population are less frequently published in the literature but are poor. The purpose of this study was to review long-term results of CAS in veteran patients with a prior history of treatment for head and/or neck cancer.

METHODS

This is a retrospective review of a veteran patient population from 1998 to 2016. All patients at our institution with a prior history of treatment for head and/or neck cancer who underwent CAS were included in the analysis. During this time period, 44 patients met inclusion criteria and were treated with 57 carotid stenting interventions. The Kaplan-Meier analysis was used to determine survival and primary patency. The secondary aims were to analyze early outcomes and to identify predictive risk factors for mortality and reintervention.

RESULTS

The mean follow-up was 42.9 ± 36.6 months. The cumulative survival at 1, 5, and 10 years was 91%, 67%, and 48%, respectively. The primary patency at 1, 5, and 10 years was 95%, 86%, and 86%, respectively. The reintervention rate was 11% (n = 6) with an assisted primary patency rate of 100%. No neurologic events occurred within 30 days. There were 3 strokes in late follow-up and no stroke-related deaths. Eighteen patients (41%) died during the follow-up period, 15 of whom died during the first 5 years of follow-up. Ten (66%) of those patients died of recurrent or active index cancer. On univariate analysis, tumor, node, metastasis stage IV was significantly associated with death (P = 0.02). Multivariate models were not statistically significant for predicting mortality or reintervention CONCLUSIONS: On the basis of the results in this series, CAS can be performed in these patients with low long-term rates of neurologic events and need for reintervention. However, the survival of patients with head and neck cancer undergoing CAS in this cohort is poor, which is consistent with other published series of patients undergoing CAS for head/neck cancer with at least 5-year follow-up. In this specific patient population, a more critical analysis of the patient's overall prognosis, especially as related to cancer, should be undertaken before offering CAS.

1004 Smith-&lt;Magenis Syndrome (SMS) Circadian Abnormalities And Biological Rhythms

Introduction

SMS is a rare neurodevelopmental disorder that manifests with craniofacial abnormalities, behavioral disturbances, and a severe sleep disorder. It has been reported that many SMS patients have an inverted melatonin secretion pattern (peaking during the daytime) although a small minority have near normal patterns. The goal of this study was to better characterize the intra- and inter-patient variability of melatonin secretion patterns and investigate a potential relationship with sleep behavior in SMS patients.

Methods

In this observational study, sleep behaviors of patients (N=8, 1 female, ages: 7 - 35) with SMS were characterized through caretaker surveys. On 3 separate occasions, patients had hourly serum melatonin levels sampled for 36 hours. From these data, peak serum melatonin concentration and time of peak concentration were determined. Inter- and intra-patient variability was characterized by zero lag correlation of the melatonin concentration timeseries across and within patients, respectively. The relationship between peak melatonin concentration, peak time, and sleep latency was analyzed by a generalized linear model, GLM.

Results

Peak melatonin concentrations varied across SMS patients with a range of 3.55pg/ml - 49.65pg/ml (mean 14.18 ± 15.19pg/ml). Time of peak melatonin concentrations ranged from 0400h-2100h (mean 1422 ± 6h). Correlation coefficients characterizing intra-patient variability ranged from -0.0098 to 0.89 (mean 0.55 ± 0.2533). Correlation coefficients characterizing inter-patient variability ranged from -0.75 to 0.79 (mean of 0.18 ± 0.52). Sleep latency ranged from 8.4min - 36.35min (mean of 21.99 ± 9.77 min). GLM analysis demonstrated a significant, positive effect of peak time with sleep latency (p=0.022).

Conclusion

Consistent with previous findings, our study confirms that SMS patients have abnormal circadian rhythms. Our work extends this body of literature by demonstrating a significant degree of inter-patient variability with relatively stable intra-patient variability. Preliminary evidence suggests that the timing of melatonin peak may be related to sleep onset latency.

Support

This work was supported by Vanda Pharmaceuticals Inc.