Intraoperative FoCUS: Training Practices and Views on Feasibility

OBJECTIVES

To investigate whether resident anesthesiologists perceive intraoperative focused cardiac ultrasonography (FoCUS) as feasible, the self-reported confidence of residents performing intraoperative FoCUS, and United States graduate medical education resident ultrasound training practices.

DESIGN

A cross-sectional survey.

SETTING

The United States Accreditation Council for Graduate Medical Education-listed anesthesiology programs over a 3-month period between June 2022 to September 2022.

PARTICIPANTS

United States anesthesiology residents.

INTERVENTIONS

A survey.

MEASUREMENTS AND MAIN RESULTS

Reported training practices were as follows: 87.3% of respondents reported formal FoCUS training, and the most commonly reported training was "lectures + live-model training under 5 hours annually" at 31%. Most respondents (82%) stated that faculty never or rarely performed bedside FoCUS, and most respondents (69%) reported no intraoperative FoCUS education exposure. The proportion of residents who reported a positive view on the perceived feasibility of intraoperative FoCUS was 53.2% for extremity surgery, 19.8% for laparoscopic surgery, 18.6% for exploratory laparotomy surgery, and 7.9% for robotic surgery. Most respondents (78.6%) indicated a lack of confidence in performing intraoperative FoCUS independently. The authors found no statistical difference in views on feasibility or reported confidence independently performing FoCUS across training years. Training that included "lectures + simulation" or "live-model" for more than 5 hours annually, faculty routinely using bedside FoCUS, and frequent exposure to intraoperative FoCUS increased the odds of reporting confidence.

CONCLUSIONS

The misconception that intraoperative FoCUS is infeasible appears prevalent, and most of the authors' respondents expressed a lack of comfort independently performing intraoperative FoCUS. Alterations of training practices, including increasing faculty usage of bedside ultrasonography, increasing trainee time performing FoCUS, and incorporating specific intraoperative ultrasound into the ultrasound curriculum, may address these deficiencies.

Impact of body mass index on surgical case durations in an academic medical center

STUDY OBJECTIVE

To investigate the association between patient body mass index (BMI) and operating room duration.

DESIGN

Retrospective cohort analysis.

SETTING

Demographic data and anesthesia/surgical times for adult surgical patients at University of Virginia Health between August 2017 and February 2019 were collected and analyzed.

PATIENTS

A total of 31,548 cases were included in the final analysis. 55% of patients were female, and 51% were classified as ASA Physical Status 2. The mean operating room (OR) duration was 144.2 min ± 112.7 (median = 118, IQR = 121). Orthopedic surgery (32%) was the most common surgery.

MEASUREMENTS

Linear mixed effects models were used to examine whether procedure intervals differed across three BMI categories (BMI < 30, 30 ≤ BMI < 40, BMI ≥ 40), considering within-surgeon correlations. Surgical times were log-transformed to correct for positive skewness.

MAIN RESULTS

The average time in the operating room was longer for patients with higher BMI (mean ± SD [median, IQR] = 139.5 ± 111.2 [113.0, IQR = 114], 150.2 ± 115.4 [125, IQR = 127], and 153.1 ± 111.1 [130, IQR = 134] for BMI < 30, 30 ≤ BMI < 40, and BMI ≥ 40), respectively. We found a 2% [95% CI = 1-3%] and 3% [95% CI = 1-5%] increase in OR time for 30 ≤ BMI < 40 and BMI ≥ 40, respectively, compared to BMI < 30, after controlling for within-surgeon correlations and covariates. The excess time was primarily determined by anesthesia times.

CONCLUSION

In an academic hospital, patients with BMI ≥ 30 required more time in the operating room than patients with BMI < 30, when controlling for confounders. This information can be incorporated into modern-day OR scheduling software, potentially resulting in more accurate case duration estimates that reduce waiting and improve OR efficiency.

Mobile health supported multi-domain recovery trajectories after major arthroplasty or spine surgery: a pilot feasibility and usability study

BACKGROUND

Recovery after surgery intersects physical, psychological, and social domains. In this study we aim to assess the feasibility and usability of a mobile health application called PositiveTrends to track recovery in these domains amongst participants undergoing hip, knee arthroplasty or spine surgery. Our secondary aim was to generate procedure-specific, recovery trajectories within the pain and medication, psycho-social and patient-reported outcomes domain.

METHODS

Prospective, observational study in participants greater than eighteen years of age. Data was collected prior to and up to one hundred and eighty days after completion of surgery within the three domains using PositiveTrends. Feasibility was assessed using participant response rates from the PositiveTrends app. Usability was assessed quantitatively using the System Usability Scale. Heat maps and effect plots were used to visualize multi-domain recovery trajectories. Generalized linear mixed effects models were used to estimate the change in the outcomes over time.

RESULTS

Forty-two participants were enrolled over a four-month recruitment period. Proportion of app responses was highest for participants who underwent spine surgery (median = 78, range = 36-100), followed by those who underwent knee arthroplasty (median = 72, range = 12-100), and hip arthroplasty (median = 62, range = 12-98). System Usability Scale mean score was 82 ± 16 at 180 days postoperatively. Function improved by 8 and 6.4 points per month after hip and knee arthroplasty, respectively. In spine participants, the Oswestry Disability Index decreased by 1.4 points per month. Mood improved in all three cohorts, however stress levels remained elevated in spine participants. Pain decreased by 0.16 (95% Confidence Interval: 0.13-0.20, p < 0.001), 0.25 (95% CI: 0.21-0.28, p < 0.001) and 0.14 (95% CI: 0.12-0.15, p < 0.001) points per month in hip, knee, and spine cohorts respectively. There was a 10.9-to-40.3-fold increase in the probability of using no medication for each month postoperatively.

CONCLUSIONS

In this study, we demonstrate the feasibility and usability of PositiveTrends, which can map and track multi-domain recovery trajectories after major arthroplasty or spine surgery.

Use of Simulation Resources for Underrepresented in Medicine Youth Engagement: A National Survey of Academic Anesthesiology Programs With Specified Diversity, Equity, and Inclusion Positions

Background The utilization of simulation resources can be an effective strategy to offer early medical exposure to underrepresented in medicine (URiM) youth populations, with the objective of promoting diversity in the field of medicine. Currently, it is unclear what proportion of academic anesthesiology programs with simulation centers utilize these resources for community engagement events. Methodology A survey was created using REDCap® and distributed via email to 38 anesthesiologists from 30 departments in the United States holding a leadership position dedicated to advancing diversity, equity, and inclusion. The survey assessed whether their programs had conducted community engagement events for URiM students, what simulation resources were available at their program, and which of these resources they had used at any community engagement events. Additionally, we assessed program characteristics such as region, academic versus community practice, and urban versus rural locations. Survey responses were collected between March and April 2023. Results We received responses from 15 of the 30 institutions sampled for an institutional response rate of 50%. The majority of respondents (86.7%) reported holding community engagement events. Most respondents reported a wide variety of simulation resources available, including 11 (73.3%) having access to full simulation centers. However, only three (27.3%) of the 11 with full simulation centers reported utilizing them for community events. Conclusions Despite the potential benefits of using simulation resources for community engagement events, our results suggest that academic anesthesiology departments may not commonly utilize simulation centers to provide URiM youth with exposure to the field of medicine. Anesthesiology departments with access to simulation resources are in a unique position to be leaders in advancing diversity in medicine by increasing URiM youth interest in medicine as a career through simulation-based exposure.

Comparison of oral versus intravenous methadone on postoperative pain and opioid use after adult spinal deformity surgery: A retrospective, non-inferiority analysis

OBJECTIVE

To compare efficacy of oral versus intravenous (IV) methadone on postoperative pain and opioid requirements after spine surgery.

METHODS

This was a retrospective, single-academic center cohort study evaluating 1010 patients who underwent >3 level spine surgery from January 2017 to May 2020 and received a one-time dose of oral or intravenous methadone prior to surgery. The primary outcome measured was postoperative opioid use in oral morphine equivalents (ME) and verbal response scale (VRS) pain scores up to postoperative day (POD) three. Secondary outcomes were time to first bowel movement and adverse effects (reintubation, myocardial infarction, and QTc prolongation) up to POD 3.

RESULTS

A total of 687 patients received oral and 317 received IV methadone, six patients were excluded. The IV group received a significantly greater methadone morphine equivalent (ME) dose preoperatively (112.4 ± 83.0 mg ME versus 59.3 ± 60.9 mg ME, p < 0.001) and greater total (methadone and non-methadone) opioid dose (119.1 ± 81.4 mg ME versus 63.9 ± 62.5 mg ME, p < 0.001), intraoperatively. Although pain scores for the oral group were non-inferior to the IV group for all postoperative days (POD), non-inferiority for postoperative opioid requirements was demonstrated only on POD 3. Based on the joint hypothesis for the co-primary outcomes, oral methadone was non-inferior to IV methadone on POD 3 only. No differences in secondary outcomes, including QTc prolongation and arrhythmias, were noted between the groups.

CONCLUSIONS

Oral methadone is a feasible alternative to IV methadone for patients undergoing spine surgery regarding both pain scores and postoperative opioid consumption.

Digitization of Symbol-Denoted Blood Pressure Data From Intraoperative Paper Health Records in a Low-Middle-Income Country Using Deep Image Segmentation and Associated Postoperative Outcomes: A Feasibility Study

BACKGROUND

In low-middle-income countries (LMICs), perioperative clinical information is almost universally collected on paper health records (PHRs). The lack of accessible digital databases limits LMICs in leveraging data to predict and improve patient outcomes after surgery. In this feasibility study, our aims were to: (1) determine the detection performance and prediction error of the U-Net deep image segmentation approach for digitization of hand-drawn blood pressure symbols from an image of the intraoperative PHRs and (2) evaluate the association between deep image segmentation-derived blood pressure parameters and postoperative mortality and length of stay.

METHODS

A smartphone mHealth platform developed by our team was used to capture images of completed intraoperative PHRs. A 2-stage deep image segmentation modeling approach was used to create 2 separate segmentation masks for systolic blood pressure (SBP) and diastolic blood pressure (DBP). Iterative postprocessing was utilized to convert the segmentation mask results into numerical SBP and DBP values. Detection performance and prediction errors were evaluated for the U-Net models by comparison with ground-truth values. Using multivariate regression analysis, we investigated the association of deep image segmentation-derived blood pressure values, total time spent in predefined blood pressure ranges, and postoperative outcomes including in-hospital mortality and length of stay.

RESULTS

A total of 350 intraoperative PHRs were imaged following surgery. Overall accuracy was 0.839 and 0.911 for SBP and DBP symbol detections, respectively. The mean error rate and standard deviation for the difference between the actual and predicted blood pressure values were 2.1 ± 4.9 and -0.8 ± 3.9 mm Hg for SBP and DBP, respectively. Using the U-Net model-derived blood pressures, minutes of time where DBP <50 mm Hg (odds ratio [OR], 1.03; CI, 1.01-1.05; P = .003) was associated with an increased in-hospital mortality. In addition, increased cumulative minutes of time with SBP between 80 and 90 mm Hg was significantly associated with a longer length of stay (incidence rate ratio, 1.02 [1.0-1.03]; P < .05), while increased cumulative minutes of time where SBP between 140 and 160 mm Hg was associated with a shorter length of stay (incidence rate ratio, 0.9 [0.96-0.99]; P < .05).

CONCLUSIONS

In this study, we report our experience with a deep image segmentation model for digitization of symbol-denoted blood pressure from intraoperative anesthesia PHRs. Our data support further development of this novel approach to digitize PHRs from LMICs, to provide accessible, curated, and reproducible data for both quality improvement- and outcome-based research.

Cross-Sectional Study of Location-Based Built Environments, Physical Activity, Dietary Intake, and Body Mass Index in Adult Twins

We examined relationships between walkability and health behaviors between and within identical twin pairs, considering both home (neighborhood) walkability and each twin's measured activity space. Continuous activity and location data (via accelerometry and GPS) were obtained in 79 pairs over 2 weeks. Walkability was estimated using Walk Score^® (WS); home WS refers to neighborhood walkability, and GPS WS refers to the mean of individual WSs matched to every GPS point collected by each participant. GPS WS was assessed within (WHN) and out of the neighborhood (OHN), using 1-mile Euclidean (air1mi) and network (net1mi) buffers. Outcomes included walking and moderate-to-vigorous physical activity (MVPA) bouts, dietary energy density (DED), and BMI. Home WS was associated with WHN GPS WS (b = 0.71, SE = 0.03, p < 0.001 for air1mi; b = 0.79, SE = 0.03, p < 0.001 for net1mi), and OHN GPS WS (b = 0.18, SE = 0.04, p < 0.001 for air1mi; b = 0.22, SE = 0.04, p < 0.001 for net1mi). Quasi-causal relationships (within-twin) were observed for home and GPS WS with walking (ps < 0.01), but not MVPA, DED, or BMI. Results support previous literature that neighborhood walkability has a positive influence on walking.

Investigating the Association Between a Risk-Directed Prophylaxis Protocol and Postoperative Nausea and Vomiting: Validation in a Low-Income Setting

BACKGROUND

The efficacy of postoperative nausea and vomiting (PONV) prevention protocols in low-income countries is not well known. Different surgical procedures, available medications, and co-occurring diseases imply that existing protocols may need validation in these settings. We assessed the association of a risk-directed PONV prevention protocol on the incidence of PONV and short-term surgical outcomes in a teaching hospital in Rwanda.

METHODS

We compared the incidence of PONV during the first 48 hours postoperatively before (April 1, 2019-June 30, 2019; preintervention) and immediately after (July 1, 2019-September 30, 2019; postintervention) implementing an Apfel score-based PONV prevention strategy in 116 adult patients undergoing elective open abdominal surgery at Kigali University Teaching Hospital in Rwanda. Secondary outcomes included time to first oral intake, hospital length of stay, and rate of wound dehiscence. Interrupted time series analyses were performed to assess the associated temporal slopes of the outcome before and immediately after implementation of the risk-directed PONV prevention protocol.

RESULTS

Compared to just before the intervention, there was no change in the odds of PONV at the beginning of the postintervention period (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.05-1.01). There was a decreasing trend in the odds of nausea (OR, 0.60; 95% CI, 0.36-0.97) per month. However, there was no difference in the incidence of nausea immediately after implementation of the protocol (OR, 0.96; 95% CI, 0.25-3.72) or in the slope between preintervention and postintervention periods (OR, 1.48; 95% CI, 0.60-3.65). In contrast, there was no change in the odds of vomiting during the preintervention period (OR, 1.01; 95% CI, 0.61-1.67) per month. The odds of vomiting decreased at the beginning of the postintervention period compared to just before (OR, 0.10; 95% CI, 0.02-0.47; P = .004). Finally, there was a significant decrease in the average time to first oral intake (estimated 14 hours less; 95% CI, -25 to -3) when the protocol was first implemented, after adjusting for confounders; however, there was no difference in the slope of the average time to first oral intake between the 2 periods ( P = .44).

CONCLUSIONS

A risk-directed PONV prophylaxis protocol was associated with reduced vomiting and time to first oral intake after implementation. There was no substantial difference in the slopes of vomiting incidence and time to first oral intake before and after implementation.

Proposed Specifiers for Conduct Disorder (PSCD): Factor Structure and Validation of the Self-Report Version in Community and Forensic Samples of Portuguese Youth

The Proposed Specifiers for Conduct Disorder (PSCD) was developed as a measure to assess the multifaceted model of psychopathic traits in children/youth (i.e., grandiose-manipulative [GM], callous-unemotional [CU], and daring-impulsive [DI] traits) in addition to Conduct Disorder (CD) symptoms. This study aims to test the psychometric properties of the PSCD-self-report version across community (n = 648; 52.9% female) and forensic male youth (n = 258) from the Portuguese population. Results supported a general factor and four specific factors (GM, CU, DI, CD), which was invariant across gender and sample type. Evidence for reliability, construct, and temporal validity were also found. Overall, the PSCD appears to be a promising measure for assessing psychopathic traits in youth from both community and forensic settings, which may contribute to the discussion around the conceptualization, assessment, predictive value, and clinical usefulness of the multifaceted model of psychopathy in youthful populations, particularly in its association with CD.

Do married and/or cohabiting individuals fare better during the COVID-19 pandemic? Satisfaction with life and depression among adult twins in the United States

Due to social distancing measures implemented to mitigate the COVID-19 pandemic, individuals are spending more time isolated at home with limited physical social interactions. The current study investigated whether marriage and/or cohabitation is associated with satisfaction with life and depression among 732 adult same-sex twin pairs (monozygotic and dizygotic) in the US using online survey data. Twin analysis showed that married and/or cohabiting individuals were more satisfied with life and less depressed than those not married and/or cohabiting. The association between marriage and/or cohabiting and satisfaction with life was not confounded by between-family factors, whereas that between depression was mediated by familial factors. These findings suggest that being in a close relationship may mitigate some of the adverse consequences of the COVID-19 pandemic. Close relationships may be an essential source of support as individuals rely on their intimate partners when faced with the uncertainty and stress of the pandemic.

Cross-sectional associations between neighbourhood walkability and objective physical activity levels in identical twins

OBJECTIVES

Physical activity is a cornerstone of chronic disease prevention and treatment, yet most US adults do not perform levels recommended for health. The neighborhood-built environment (BE) may support or hinder physical activity levels. This study investigated whether identical twins who reside in more walkable BEs have greater activity levels than twins who reside in less walkable BEs (between-twin analysis), and whether associations remain significant when controlling for genetic and shared environmental factors (within-twin analysis).

DESIGN

A cross-sectional study.

SETTING

The Puget Sound region around Seattle, Washington, USA.

PARTICIPANTS

The sample consisted of 112 identical twin pairs who completed an in-person assessment and 2-week at-home measurement protocol using a global positioning system (GPS)monitor and accelerometer.

EXPOSURE

The walkability of each participants' place of residence was calculated using three BE dimensions (intersection density, population density and destination accessibility). For each variable, z scores were calculated and summed to produce the final walkability score.

OUTCOMES

Objectively measured bouts of walking and moderate-to-vigorous physical activity (MVPA), expressed as minutes per week.

RESULTS

Walkability was associated with walking bouts (but not MVPA) within the neighbourhood, both between (b=0.58, SE=0.13, p<0.001) and within pairs (b=0.61, SE=0.18, p=0.001). For a pair with a 2-unit difference in walkability, the twin in a more walkable neighbourhood is likely to walk approximately 16 min per week more than the co-twin who lives in a less walkable neighbourhood.

CONCLUSIONS

This study provides robust evidence of an association between walkability and objective walking bouts. Improvements to the neighbourhood BE could potentially lead to increased activity levels in communities throughout the USA.

The pillars of health: influence of multiple lifestyle behaviors on body mass index and depressive symptoms in adult twins

Background

Guidelines promoting healthy lifestyles are cornerstones of chronic disease prevention and treatment. The purpose of this study is to investigate independent and joint associations of five key health behaviors with health outcomes (body mass index (BMI kg/m²) and depressive symptoms) in adult twins.

Methods

We included 6,048 twin pairs from a community-based registry. Five key health behaviors were: (1) ≥ 8 h of sleep per night, (2) ≥ 5 servings of fruits and vegetables daily, (3) ≤ 2 h sedentary time per day, (4) ≥ 150 min of moderate-to-vigorous physical activity (MVPA) per week, and (5) no smoking. We analyzed phenotypic associations between behaviors and outcomes; whether phenotypic associations were confounded by additive genetic and shared environmental factors within twin pairs (“quasi-causal” associations); and which behaviors, considered simultaneously, had the largest associations with outcomes.

Results

We found negative phenotypic associations between number of behaviors achieved with BMI and depressive symptoms score (ps < 0.05). Associations remained significant, though attenuated, when controlling for genetic and shared environmental factors, and demographics, for depressive symptoms score but not BMI (p < 0.05). Quantitative variable importance measures derived from regression tree models showed sedentary time and MVPA were the most important variables in partitioning twins with different BMI, and smoking and sedentary time for partitioning twins with different depressive symptoms score.

Conclusions

Achievement of commonly endorsed health behaviors is associated with lower BMI (especially sedentary and MVPA targets) and depressive symptoms score (especially sedentary and smoking targets). This provides further support of health behavior promotion to improve health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13901-7.

Sequence Variant in the TRIM39-RPP21 Gene Readthrough is Shared Across a Cohort of Arabian Foals Diagnosed with Juvenile Idiopathic Epilepsy

Juvenile idiopathic epilepsy (JIE) is a self-limiting neurological disorder with a suspected genetic predisposition affecting young Arabian foals of the Egyptian lineage. The condition is characterized by tonic-clonic seizures with intermittent post-ictal blindness, in which most incidents are sporadic and unrecognized. This study aimed to identify genetic components shared across a local cohort of Arabian foals diagnosed with JIE via a combined whole genome and targeted resequencing approach: Initial whole genome comparisons between a small cohort of nine diagnosed foals (cases) and 27 controls from other horse breeds identified variants uniquely shared amongst the case cohort. Further validation via targeted resequencing of these variants, that pertain to non-intergenic regions, on additional eleven case individuals revealed a single 19bp deletion coupled with a triple-C insertion (Δ19InsCCC) within the TRIM39-RPP21 gene readthrough that was uniquely shared across all case individuals, and absent from three additional Arabian controls. Furthermore, we have confirmed recent findings refuting potential linkage between JIE and other inherited diseases in the Arabian lineage, and refuted the potential linkage between JIE and genes predisposing a similar disorder in human newborns. This is the first study to report a genetic variant to be shared in a sub-population cohort of Arabian foals diagnosed with JIE. Further evaluation of the sensitivity and specificity of the Δ19InsCCC allele within additional cohorts of the Arabian horse is warranted in order to validate its credibility as a marker for JIE, and to ascertain whether it has been introduced into other horse breeds by Arabian ancestry.

Changes in physical activity levels and mental health during COVID-19: Prospective findings among adult twin pairs

BACKGROUND

Physical distancing and other COVID-19 pandemic mitigation strategies have negatively impacted physical activity (PA) levels and mental health in cross-sectional studies. The purpose of this study was to investigate associations between changes in PA and mental health outcomes during the COVID-19 pandemic, following implementation of mitigation strategies, in a sample of adult twins.

METHODS

This was a prospective study of 3,057 adult twins from the Washington State Twin Registry. Study participants completed online surveys in 2020, at baseline (March 26 -April 5), and three follow-up waves (W1: April 20 -May 3; W2: Jul 16 -Aug 2; W3: Sept 16 -Oct 1). Physical activity was operationalized as self-reported moderate-to-vigorous PA (MVPA) and neighborhood walking (minutes/week), and mental health outcomes, operationalized as self-reported anxiety and perceived stress were assessed in the three waves of follow-up. Latent growth curve models (LGCMs) were used to assess changes in PA and mental health outcomes over time. Parallel LGCMs were used to estimate the cross-sectional, parallel, and prospective associations between PA and mental health over time. All models took into within-pair correlations and adjusted for age, sex, and race.

RESULTS

Individuals' amount of MVPA and walking decreased over time, whereas levels of anxiety remained stable, and stress increased slightly. Cross-sectional associations observed between both PA predictors and mental health outcomes were weak. After taking into account cross-sectional associations between PA and mental health outcomes, changes in PA over time were not associated with changes in mental health outcomes over time.

CONCLUSIONS

Over a time period aligned with COVID-19 mitigation strategies and social restrictions, changes in physical activity was not associated with changes in anxiety or stress levels in the current sample. Nonetheless, the average decline in PA over time is worrisome. Public health resources should continue to promote PA as a means to improve physical health during the pandemic.

Differences in Stress and Anxiety Among Women With and Without Children in the Household During the Early Months of the COVID-19 Pandemic

The COVID-19 pandemic and resulting lockdowns have had a disproportionate impact on parents of children under 18, particularly women. Mandatory school closures and loss of childcare resulted in parents balancing work, teaching, and childcare needs. A number of studies have examined changes in mental health of parents, but to date no studies have compared the differences in stress and anxiety levels between women with and without children in the United States. Adult women from the Washington State Twin Registry (WSTR) (N = 1,014, pair N = 529) and mothers of twin children enrolled in the WSTR (N = 147) completed an online survey examining several health-related behaviors and outcomes and their self-reported changes due to COVID-19. We conducted two studies to examine the impact of children on stress and anxiety levels among women. In study 1, we assessed whether women living in households with children under the age of 18 have higher levels of stress and anxiety than those without children in their household. We found that perceived stress levels did not differ between women with and without children in the household, but anxiety levels were higher among women living with children than those without. In study 2, we assessed whether the correlation between children in the household and stress/anxiety is accounted for by non-random genetic and environmental selection effects, causal processes, or both using a sample of adult female twins. We found that the presence of children in the household was associated with higher levels of stress and anxiety. However, this association is confounded by genetic and shared environmental factors. Our findings highlight the need to provide supporting resources to women living with children in the household during and after the COVID-19 pandemic.

Measurement of neighborhood-based physical activity bouts

This study examined how buffer type (shape), size, and the allocation of activity bouts inside buffers that delineate the neighborhood spatially produce different estimates of neighborhood-based physical activity. A sample of 375 adults wore a global positioning system (GPS) data logger and accelerometer over 2 weeks under free-living conditions. Analytically, the amount of neighborhood physical activity measured objectively varies substantially, not only due to buffer shape and size, but by how GPS-based activity bouts are identified with respect to containment within neighborhood buffers. To move the "neighborhood-effects" literature forward, it is critical to delineate the spatial extent of the neighborhood, given how different ways of measuring GPS-based activity containment will result in different levels of physical activity across different buffer types and sizes.

Is COVID-19 Keeping us Up at Night? Stress, Anxiety, and Sleep Among Adult Twins

In response to the COVID-19 pandemic, a variety of social distancing measures to mitigate the virus outbreak have been implemented. These measures may have unintended consequences on individuals' well-being, such as increased stress, anxiety, and sleep disruptions. We investigated the extent to which individuals' mental health status is associated with perceived changes in sleep amount and sleep quality among a sample of adult twin pairs (N = 909 pairs; 77% MZ, 23% DZ), less than a month after the outbreak was declared a pandemic by the World Health Organization. About half of participants reported no change in sleep amount (50.1%) or sleep quality (55.6%). Approximately one-third of the participants had increased amount of sleep (29.8%), and 32.9% reported a decrease in sleep quality. We found that stress and anxiety levels were associated with sleep reduction (ORs = 2.36 and 3.12 for stress and anxiety, respectively) and poorer sleep quality (ORs = 2.45 and 3.73 for stress and anxiety, respectively), even after taking into account between-family confounds. A much smaller association was observed between levels of stress and anxiety and increased sleep amount (ORs = 1.42 and 1.60 for stress and anxiety, respectively) and sleep quality (OR = 1.21 and 1.29 for stress and anxiety, respectively), which was no longer significant after controlling for between-family confounds. Our results demonstrate that stress and anxiety associated with the COVID-19 pandemic and social distancing measures may be linked to reduced sleep amount and quality.

RIFM low-exposure fragrance ingredients safety assessment

The existing information supports the use of these materials as described in this safety assessment. The 167 materials identified in this assessment were evaluated for genotoxicity, repeated dose toxicity, reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Target data, read-across analogs and TTC show that these materials are not expected to be genotoxic. The repeated dose, reproductive, and local respiratory toxicity endpoints were evaluated using the TTC for their respective Cramer Classes (see Fig. 1 below) and the exposure to these materials is below the TTC. The skin sensitization endpoint was completed using the DST for non-reactive and reactive materials (900 μg/cm² and 64 μg/cm², respectively); exposures are below the DST. The phototoxicity/photoallergenicity endpoints were evaluated based on UV spectra; these materials are not expected to be phototoxic/photoallergenic. The environmental endpoints were evaluated; the materials were found not to be PBT as per the IFRA Environmental Standards, and their risk quotients, based on their current volume of use in Europe and North America (i.e., PEC/PNEC), are <1.

Paediatric glaucoma in Hong Kong: a multicentre retrospective analysis of epidemiology, presentation, clinical interventions, and outcomes

PURPOSE

To document the epidemiology, presentation, clinical interventions, and outcomes of paediatric glaucoma in Hong Kong.

METHODS

This multicentre territory-wide retrospective study was performed by reviewing charts of patients with paediatric glaucoma in six clusters of the Hong Kong Hospital Authority and The Chinese University of Hong Kong from 2006 to 2015.

RESULTS

This study included 150 eyes of 98 patients with paediatric glaucoma (presenting age: 5.2±5.7 years). Of them, 35 eyes (23.3%) had primary congenital glaucoma, 22 eyes (14.7%) had juvenile open-angle glaucoma, and 93 eyes (62.0%) had secondary glaucoma. The most prevalent types of secondary glaucoma were lens-related after cataract extraction (18.0%), Axenfeld-Rieger anomaly (5.3%), uveitis (5.3%), Sturge-Weber syndrome (4.7%), and traumatic (3.3%). The most common clinical presentations were parental concerns (20.7%) including cloudy cornea (12.7%) and tearing/photophobia (8.0%), followed by poor visual acuity (18.0%), high intraocular pressure (13.3%), and strabismus (6.0%). The follow-up duration was 8.46±6.51 years. Furthermore, 63.2% of eyes with primary glaucoma and 45.2% of eyes with secondary glaucoma were treated surgically. The final visual acuity was 0.90±0.98 LogMAR; intraocular pressure was 18.4±6.6 mm Hg; and number of glaucoma medications was 2.22±1.61.

CONCLUSION

Primary congenital glaucoma was most prevalent, followed by juvenile open-angle glaucoma and aphakic glaucoma. Most eyes with primary glaucoma required surgical treatment. Parental concerns were important clinical presentations. Basic assessments by healthcare providers to identify glaucoma signs (eg, poor visual acuity, high intraocular pressure, and strabismus) warranted prompt referral to an ophthalmologist.

RIFM fragrance ingredient safety assessment, 3,7-dimethyl-1,3,6-octatriene, CAS registry number 13877-91-3

The existing information supports the use of this material as described in this safety assessment. 3,7-Dimethyl-1,3,6-octatriene was evaluated for genotoxicity, repeated dose toxicity, developmental and reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Data from 3,7-dimethyl-1,3,6-octatriene and read-across analog myrcene (β-myrcene; CAS # 123-35-3) show that 3,7-dimethyl-1,3,6-octatriene is not expected to be genotoxic and provide a calculated margin of exposure (MOE) >100 for the repeated dose toxicity and developmental and reproductive toxicity endpoints. The skin sensitization endpoint was completed using the dermal sensitization threshold (DST) for non-reactive materials (900 μg/cm 2 ); exposure is below the DST. The phototoxicity/photoallergenicity endpoints were evaluated based on ultraviolet (UV) spectra; 3,7-dimethyl-1,3,6- octatriene is not expected to be phototoxic/photoallergenic. The local respiratory toxicity endpoint was evaluated using the threshold of toxicological concern (TTC) for a Cramer Class I material, and the exposure to 3,7-dimethyl-1,3,6-octatriene is below the TTC (1.4 mg/day). The environmental endpoints were evaluated; 3,7-dimethyl-1,3,6- octatriene was found not to be persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) Environmental Standards, and its risk quotients, based on its current volume of use in Europe and North America (i.e., Predicted Environmental oncentration/Predicted No Effect Concentration [PEC/PNEC]), are <1.

RIFM fragrance ingredient safety assessment, p-tolualdehyde, CAS Registry Number 104-87-0

The existing information supports the use of this material as described in this safety assessment. p-Tolualdehyde was evaluated for genotoxicity, repeated dose toxicity, developmental and reproductive toxicity, local respiratory toxicity, phototoxicity, skin sensitization potential, and environmental safety. Data from read-across analog benzaldehyde (CAS # 100-52-7) show that p-tolualdehyde is not expected to be genotoxic. Data from read-across analog cuminaldehyde (CAS # 122-03-2) provided p-tolualdehyde a No Expected Sensitization Induction Level (NESIL) of 1100 μg/cm² for the skin sensitization endpoint. The repeated dose toxicity, developmental and reproductive toxicity, and local respiratory toxicity endpoints were completed using the threshold of toxicological concern (TTC) for a Cramer Class I material, and the exposure to p-tolualdehyde is below the TTC (0.03 mg/kg/day, 0.03 mg/kg/day, and 1.4 mg/day, respectively). The phototoxicity/photoallergenicity endpoints were evaluated based on data from read-across analog 4-ethylbenzaldehyde (CAS # 4748-78-1); p-tolualdehyde is not expected to be phototoxic/photoallergenic. The environmental endpoints were evaluated; p-tolualdehyde was found not to be persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) Environmental Standards, and its risk quotients, based on its current volume of use in Europe and North America (i.e., Predicted Environmental Concentration/Predicted No Effect Concentration [PEC/PNEC]), are <1.

Psychopathic Expression From Early to Late Adulthood: An Item Response Theory Analysis of the Hare Psychopathy Checklist-Revised

Several investigators have assessed the Psychopathy Checklist-Revised (PCL-R) for invariance across offender ethnicities and in correctional and forensic-psychiatric contexts. Yet we do not know whether, or to what extent, item properties among male offenders vary throughout adulthood. With a combined sample of PCL-R data on offenders from Canada and the United States (N = 4,820), we measured item properties for offenders in age groups of Early (18-30 years old), Middle (31-49 years old), and Late (50+ years old) adulthood. Nine items showed differential item functioning across age group comparisons. Among the Early group, the PCL-R Interpersonal and Affective traits were most informative for measuring the latent trait of psychopathy. Among the Late group, the PCL-R Lifestyle and Antisocial items were most informative for the latent trait. These differences in item information illustrate how psychopathy manifests in male offenders throughout adulthood.

Stress, Anxiety, and Change in Alcohol Use During the COVID-19 Pandemic: Findings Among Adult Twin Pairs

The novel coronavirus (COVID-19) has impacted the lives of people worldwide since being declared a pandemic on March 11, 2020. Social restrictions aimed at flattening the curve may be associated with an increase in stress and anxiety, which may increase the use of alcohol as a coping mechanism. The objective of this study was to examine if stress and anxiety were associated with changes in alcohol use in a sample of adult twins. Twins allowed us to control for genetic and shared environmental factors that would confound the alcohol - mental health relationship. Twins (N = 3,971; 909 same-sex pairs) from the Washington State Twin Registry (WSTR) completed an online survey examining several health-related behaviors and outcomes and their self-reported changes due to COVID-19. About 14% of the respondents reported an increase in alcohol use. We found an association between both stress and anxiety and increased alcohol use, where twins with higher levels of stress and anxiety were more likely to report an increase in alcohol consumption. The associations were small and confounded by between-family factors and demographic characteristics. However, there was no significant difference in stress or anxiety levels between non-drinkers and those who reported no change in alcohol use. Our findings suggest that individuals' mental health may be associated with changes in alcohol use during the COVID-19 pandemic.

RIFM fragrance ingredient safety assessment, 2-decanone, CAS Registry Number 693-54-9

The existing information supports the use of this material as described in this safety assessment. 2-Decanone was evaluated for genotoxicity, repeated dose toxicity, reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Data from read-across analog 2-heptanone (CAS # 110-43-0) show that 2-decanone is not expected to be genotoxic. Data on read-across analog 2-heptanone (CAS # 110-43-0) provide a calculated margin of exposure (MOE) > 100 for the repeated dose toxicity and reproductive toxicity endpoints. The skin sensitization endpoint was completed using the dermal sensitization threshold (DST) for non-reactive materials (900 μg/cm²); exposure is below the DST. The phototoxicity/photoallergenicity endpoints were evaluated based on ultraviolet (UV) spectra; 2-decanone is not expected to be phototoxic/photoallergenic. For the local respiratory endpoint, a calculated MOE >100 was provided by the read-across analog 4-methyl-2-pentanone (CAS # 108-10-1). The environmental endpoints were evaluated; for the hazard assessment based on the screening data, 2-decanone is not persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) Environmental Standards. For the risk assessment, 2-decanone was not able to be risk screened as there were no reported volumes of use for either North America or Europe in the 2015 IFRA Survey.

RIFM fragrance ingredient safety assessment, 2-phenylpropionaldehyde, CAS Registry Number 93-53-8

The existing information supports the use of this material as described in this safety assessment. 2-Phenylpropionaldehyde was evaluated for genotoxicity, repeated dose toxicity, developmental and reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Data on read-across analogs 3-phenylbutanal (CAS # 16251-77-7) and isopropylphenylbutanal (CAS # 125109-85-5) show that this material is not expected to be genotoxic. Data from the target material provide a calculated margin of exposure (MOE) >100 for the repeated dose toxicity endpoint and a No Expected Sensitization Induction Level (NESIL) of 380 μg/cm² for the skin sensitization endpoint. The developmental and reproductive toxicity and the local respiratory toxicity endpoints were completed using the threshold of toxicological concern (TTC) for a Cramer Class I material (0.03 mg/kg/day and 1.4 mg/day, respectively). The phototoxicity/photoallergenicity endpoints were evaluated based on ultraviolet (UV) spectra; 2-phenylpropionaldehyde is not expected to be phototoxic/photoallergenic. The environmental endpoints were evaluated; 2-phenylpropionaldehyde was found not to be persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) Environmental Standards, and its risk quotients, based on its current volume of use in Europe and North America (i.e., Predicted Environmental Concentration/Predicted No Effect Concentration [PEC/PNEC]), are <1.

RIFM fragrance ingredient safety assessment, 3,7-dimethyl-3,6-octadienal, CAS registry number 55722-59-3

The existing information supports the use of this material as described in this safety assessment. 3,7-Dimethyl-3,6-octadienal was evaluated for genotoxicity, repeated dose toxicity, developmental and reproductive toxicity, local respiratory toxicity, phototoxicity/photoallergenicity, skin sensitization, and environmental safety. Data from read-across analog citral (CAS # 5392-40-5) show that 3,7-dimethyl-3,6-octadienal is not expected to be genotoxic and provided a calculated margin of exposure (MOE) >100 for the repeated dose toxicity and developmental and reproductive endpoints. Data from the read-across analog citronellal (CAS # 106-23-0) provided 3,7-dimethyl-3,6-octadienal a No Expected Sensitization Induction Level (NESIL) of 7000 μg/cm² for the skin sensitization endpoint. The phototoxicity/photoallergenicity endpoints were evaluated based on ultraviolet (UV) spectra; 3,7-dimethyl-3,6-octadienal is not expected to be phototoxic/photoallergenic. The local respiratory toxicity endpoint was evaluated using the threshold of toxicological concern (TTC) for a Cramer Class I material, and the exposure to 3,7-dimethyl-3,6-octadienal is below the TTC (1.4 mg/day). The environmental endpoints were evaluated; 3,7-dimethyl-3,6-octadienal was found not to be persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) Environmental Standards, and its risk quotients, based on its current volume of use in Europe and North America (i.e., Predicted Environmental Concentration/Predicted No Effect Concentration [PEC/PNEC]), are <1.

RIFM fragrance ingredient safety assessment, phenylacetaldehyde, CAS Registry Number 122-78-1

The existing information supports the use of this material as described in this safety assessment. The material (phenylacetaldehyde) was evaluated for genotoxicity, repeated dose toxicity, developmental and reproductive toxicity, local respiratory toxicity, phototoxicity, skin sensitization, and environmental safety. Data show that phenylacetaldehyde is not genotoxic and provide a calculated margin of exposure (MOE) > 100 for the repeated dose and developmental and reproductive toxicity endpoints. Data from phenylacetaldehyde provided a No Expected Sensitization Induction Level (NESIL) of 590 μg/cm² for the skin sensitization endpoint. The local respiratory toxicity endpoint was completed using the threshold of toxicological concern (TTC) for a Cramer Class I material, and the exposure to phenylacetaldehyde was below the TTC (0.03 mg/kg/day, 0.03 mg/kg/day, and 1.4 mg/day, respectively). The phototoxicity/photoallergenicity endpoint was completed based on data and ultraviolet (UV) spectra; phenylacetaldehyde is not expected to be phototoxic/photoallergenic. The environmental endpoints were evaluated; phenylacetaldehyde was not found to be persistent, bioaccumulative, and toxic (PBT) as per the International Fragrance Association (IFRA) environmental standards and its risk quotients, based on its current volume of use in Europe and North America (i.e., Predicted Environmental Concentration/Predicted No Effect Concentration [PEC/PNEC]) are <1.