LDL cholesterol. Among individuals with low (<130 mg/dL) LDL cholesterol, we undertook detailed profiling of circulating atherogenic lipoproteins in relation to incident cardiovascular disease in 2 populations.Levels of LDL (low‐density lipoprotein) cholesterol in the population are declining, and increasing attention is being focused on residual lipid‐related pathways of atherosclerotic cardiovascular disease risk beyond LDL and VLDL (very low‐density lipoprotein) particle subclasses in 11 984 JUPITER trial participants (NCT00239681). Adjusted Cox models examined cardiovascular disease risk associated with lipoprotein measures according to treatment allocation. Risk (adjusted hazard ratio [95%CI] per SD increment) among placebo‐allocated participants was associated with total LDL particles  and total VLDL particles , as well as apolipoprotein B, non–high‐density lipoprotein cholesterol, and triglycerides, but not LDL‐c. Rosuvastatin reduced LDL measures but had variable effects on triglyceride and VLDL measures. On‐statin levels of the smallest VLDL particle subclass were associated with a 68% per‐SD  increase in residual risk—this risk was related to VLDL cholesterol and not triglyceride or larger VLDL particles. There was evidence that residual risk prediction during statin therapy could be significantly improved through the inclusion of key VLDL measures . In an independent, prospective cohort of 4721 individuals referred for cardiac catheterization (CATHGEN), similar patterns of lipoprotein‐related risk were observed.We performed proton nuclear magnetic resonance spectroscopy to quantify concentrations of LDL cholesterol was low. VLDL lipoproteins, particularly the smallest remnant subclass, may represent unused targets for risk prediction and potential therapeutic intervention for reducing residual risk.Atherogenic lipoprotein particle concentrations were associated with cardiovascular disease risk when URL: http://www.clinicaltrials.gov. Unique identifier: NCT00239681. Among a population intended to represent the growing number of individuals with low low‐density lipoprotein cholesterol, atherogenic lipoprotein particle concentrations (low‐density lipoprotein and very low‐density lipoprotein particles) were markers of residual atherosclerotic cardiovascular disease risk.Among individuals with the lowest low‐density lipoprotein cholesterol on statin, the smallest subclass of very low‐density lipoprotein was strongly associated with residual risk.This risk was related to the cholesterol carried in small very low‐density lipoprotein, and not triglyceride.Similar patterns were observed in an independent, diverse population of individuals referred for cardiac catheterization at a single center.Species of triglyceride‐rich lipoproteins (very low‐density lipoproteins) may represent unused clinical targets for risk prediction and potential therapeutic intervention in the prevention of atherosclerotic cardiovascular disease, particularly among individuals with low‐density lipoprotein cholesterol reduction on statin.Triglyceride level may incompletely reflect risk differentially related to triglyceride‐rich lipoprotein subclasses.Detailed phenotyping of the circulating lipid and lipoprotein milieu could improve risk assessment, as well as advance the evaluation of emerging therapies to prevent cardiovascular disease.Population levels of LDL‐c (low‐density lipoprotein cholesterol) are declining with increasing adherence to healthy lifestyle and pharmacologic interventions.1H NMR) spectroscopy can quantify concentrations, subclass distributions, composition, and size of atherogenic LDL particles (LDL‐p) and very low‐density lipoprotein particles (VLDL‐p) in circulation.To understand the residual markers of lipid‐ and lipoprotein‐related risk in the era of LDL‐c reduction and to forecast the emergence of such alternate risk pathways, we examined populations of individuals with low <130 mg/dL) LDL‐c with advanced lipoprotein profiling. Detailed lipoprotein phenotyping by proton nuclear magnetic resonance .1H NMR lipoprotein measurements on fasting blood samples from 11 984 participants  who consented to and provided additional blood collection with sufficient plasma available. In the placebo‐allocated arm, baseline lipoprotein measurements were used to identify lipoproteins associated with risk of incident CVD in untreated individuals. In the statin‐allocated arm, (1) change in lipoprotein measurements from baseline to 12 months after randomization was used to understand the effects of statin therapy on lipoprotein subfractions, and (2) on‐statin (12 month) lipoprotein measurements were used to identify lipoproteins associated with residual on‐statin risk of incident CVD.We performed Standard lipid measurements were performed on fasting samples by a central laboratory.1H NMR spectroscopy (400 MHz) LipoProfile III measurements were performed on stored plasma samples by LipoScience, Inc . NMR was used to quantify total LDL‐p and its lipoprotein subclass concentrations , and average LDL particle size. Total VLDL‐p and its subclasses  were quantified, as well the concentration of VLDL and chylomicron triglyceride (VLDL/CM TG) and cholesterol (VLDL‐c). We also examined formulaic remnant cholesterol, which was calculated as total cholesterol minus HDL‐c minus LDL‐c. .P<0.10) starting with all variables in model 2; discrimination was assessed with Harrell C‐index, and the likelihood ratio test was used to determine if model 2 provided significantly improved discrimination over this parsimonious model. Analyses were performed using SAS version 9.3 . A 2‐tailed P<0.05 was considered statistically significant. The study was approved by a local Institutional Review Board, and subjects provided informed consent.Medians  were displayed for continuous variables. Lipoprotein change was evaluated using the Wilcoxon signed‐rank test. Exposure time was calculated as the time from randomization to end‐point occurrence or censoring . Cox proportional hazards models were used to calculate hazard ratios and 95% CIs for CVD in relation to per‐SD increments in measures. Nonnormally distributed data were  log transformed. Additionally, risk was examined across lipoprotein tertiles. Models were adjusted for age, sex, race, smoking, family history of premature coronary disease, body‐mass index, systolic blood pressure, fasting glucose, and hsCRP. Sensitivity analyses mutually adjusting for other NMR lipoprotein subclasses were performed,Study participants had a median  age of 66 60, 71) years, and were 36% female. Except for race/ethnicity, participants in the current study were generally representative of those in the original JUPITER trial , moderately with apoB, non‐HDL‐c, and VLDL‐c , and not with LDL‐c (r=0.01).Total LDL‐p and apoB were strongly correlated at baseline Table , and LDLAmong the 11 984 JUPITER participants, a total of 296 primary events and 489 expanded end points occurred over a median follow‐up of 2.0 maximum 5.0) years, representing 27 864 person‐years. Among participants in the placebo‐allocated arm  but not for the individual LDL subclasses. Smaller LDL size was a marker of increased risk, but this was no longer significant after additionally adjusting for LDL‐p—as previously suggestedConversely, most VLDL‐p subfractions, as well as total VLDL‐p and NMR‐determined VLDL/CM triglycerides, were associated with increased risk of the primary Figure  or expanRosuvastatin therapy produced large median  percentage reductions in LDL‐c , apoB , and non‐HDL‐c , apAmong participants in the statin‐allocated arm with on‐statin measures N=4386), median LDL‐c was 55 mg/dL, and triglyceride was 102 mg/dL. In this population, standard lipid and apolipoprotein measures were marginally associated with risk  and systolic blood pressure (144±25 mm Hg). Among these 2149 individuals, 154 events occurred over median (maximum) 5.0 (13.3) years of follow‐up. Total VLDL‐p was significantly associated with risk of myocardial infarction, driven by the small VLDL lipoprotein subclass , sex , and racial (74.2% white) distribution as well as based on body‐mass index (30.1±7.4 kg/mP=0.50) with the addition of all NMR lipoprotein measures (24 variables): 0.664  to 0.668 . A baseline parsimonious model  identified age, sex, smoking, family history, and medium VLDL‐p as top predictor variables. Conversely for residual risk models, discrimination was significantly improved by a model that included all of the NMR variables (24 degrees of freedom) compared to a model with only clinical and standard lipid variables (12 degrees of freedom): C=0.780  versus 0.712 ; P=0.0001. The parsimonious model for residual risk selected age, sex, smoking, hsCRP, VLDL‐c, small LDL‐p, and VLDL size as top predictors.In JUPITER the C‐statistic (a measure of model discrimination) for the baseline CVD risk model  for the placebo group was not significantly changed  LDL‐c. We observed that, among such individuals, risk was associated with lipoprotein particle concentration, including LDL and VLDL subfractions. Intriguingly, among individuals on statin therapy (median LDL‐c 55 mg/dL), the lipoprotein subclass small VLDL‐p (and its associated cholesterol) conferred an ≈70% per‐SD increase in residual risk, corresponding to a 3.7‐fold increase in risk among those in the highest tertile. These observations were extended using a distinct, diverse cohort referred for cardiac catheterization (CATHGEN); as refinement of the population based on LDL‐c <130 mg/dL or statin prescription was undertaken, the magnitude of risk related to lipoprotein subclasses appeared amplified . Exploratory analyses suggested that on‐statin residual risk prediction could be significantly improved beyond known clinical and standard lipid risk factors with the inclusion of NMR‐based VLDL measurements. Overall, our results suggest a potential role for VLDL lipoproteins in the development of CVD events, particularly among individuals with lower LDL‐c—a rapidly growing population in clinical practiceThis study was designed to identify circulating lipoproteins measured by ly low <10 mg/dL Lr=0.79), the magnitude of risk associated with apoB was somewhat greater than that for LDL‐p, consistent with findings from the Women's Health Study.We observed that baseline apoB and LDL‐p were associated with risk of incident CVD. Although both measures were highly correlated  was strongly associated with risk in the statin group. VLDL  are believed to confer atherogenic risk related to their cholesterol content ,Our study is novel in its consideration of NMR‐based atherogenic lipoprotein measures among dedicated populations of individuals with low (<130 mg/dL) LDL‐c, an increasingly prevalent population in the era of LDL‐c reduction. Our findings support and extend previous observations from other cohorts, wherein lipoprotein particle concentration measured by apoB and NMR (LDL‐p) was associated with CVD events among statin‐treated secondary prevention individuals.r=0.22). In other cohorts, NMR and ion mobility have also demonstrated differential resolution of the proatherogenic effects of VLDL.The risk estimates observed with NMR are largely in agreement with those recently obtained in the same cohort using electrospray ion mobility,Our study has several potential limitations. First, the follow‐up duration in JUPITER was relatively short for a primary prevention study . Nonetheless, event rates were sufficiently high to detect a number of expected and novel associations, and the longer follow‐up in CATHGEN (median [maximum] 5.0 [13.3] years) suggested longitudinal extrapolation of these results. Second, all JUPITER study participants had elevated hsCRP. Systemic inflammation has been shown to affect the composition of the lipoprotein milieu, including VLDL.In conclusion, among individuals with low (<130 mg/dL) LDL‐c, risk remains associated with lipoprotein particle concentration, including VLDL lipoproteins. We observed on‐statin risk strongly associated with small VLDL‐p—risk that appears to be triglyceride‐independent and instead related to the cholesterol carried by these small VLDL particles. Overall, these hypothesis‐generating findings draw attention to the potential importance of VLDL lipoproteins, in particular small remnant particles, which are associated with risk but are currently not the target of prediction or therapeutic intervention. Additional studies are needed to validate these findings and assess the potential causal role of these lipoproteins as determinants of CVD risk.Lawler received support from NIH T32 (HL007575), NIH Loan Repayment Program, and Brigham and Women's Hospital, and currently receives support from the Peter Munk Cardiac Centre, University Health Network, the University of Toronto, and the Heart and Stroke/Richard Lewar Center for Excellence in Cardiovascular Research. Akinkoulie receives support from NIH T32 (HL007575). The research for this article was supported by the National Heart, Lung, and Blood Institute of the NIH under Award Numbers R01HL117861 and R01HL117861‐S1 and ‐S2 to Mora, and by the Molino Family Trust. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funding agency had no role in the design and execution of the current study. The JUPITER trial (NCT00239681) was funded by AstraZeneca, who had no role in the design and execution of this study. LipoScience (now LabCorp) performed the NMR lipoprotein analysis for this study at no additional cost.Mora received research grant support from Atherotech Diagnostics for research outside the current work and served as a consultant to Amgen, Lilly, Pfizer, Cerenis Therapeutics, and Quest Diagnostics. Glynn received research grant support from AstraZeneca. Ridker received research grant support from AstraZeneca, Kowa, Novartis, Amgen, Pfizer, and NHLBI and is listed as a coinventor on patents held by the Brigham and Women's Hospital related to the use of inflammatory biomarkers in CVD (licensed to AstraZeneca and Siemens). All other authors report no disclosures. Shah, Craig, and Kraus received research funding from LipoScience (now LabCorp) during this funding period. Chu is currently an employee at Merck but was not during the conduct of this study.


In this work, we have designed, fabricated and experimentally characterized a printed graphene nano-flakes enabled flexible and conformable wideband radar absorber. The absorber covers both X (8–12 GHz) and Ku (12–18 GHz) bands and is printed on flexible substrate using graphene nano-flakes conductive ink through stencil printing method. The measured results show that an effective absorption (above 90%) bandwidth spans from 10.4 GHz to 19.7 GHz, namely a 62% fraction bandwidth, with only 2 mm thickness. The flexibility of the printed graphene nano-flakes enables the absorber conformably bending and attaching to a metal cylinder. The radar cross section (RCS) of the cylinder with and without absorber attachment has been compared and excellent absorption has been obtained. Only 3.6% bandwidth reduction has been observed comparing to that of un-bended absorber. This work has demonstrated unambiguously that printed graphene can provide flexible and conformable wideband radar absorption, which extends the graphene’s application to practical RCS reductions. Radar absorbers are widely used in both civil and military applications such as EMI, EMC, antenna pattern shaping, stealth technology and etc.1236789111314Ω/sq16252627With the development of the printed electronics, many conductive inks are developed and can be used to replace conventional conductors161718192021171820161620However CVD/exfoliated graphene absorbers need clean room process and are too expensive for practically deployable radar applications. Graphene nano-flakes ink and its printed products are obviously preferable alternative due to its compatibility with mass-production printing process and low fabrication costs2930313233313233Ω/sq. The geometrical parameters in a1 = 3.75 mm, a2 = 2.8 mm, a3 = 2.1 mm, b1 = 3.2 mm, b2 = 2.25 mm, d = 1.25 mm, l1 = 5.0 mm, l2 = 4.0 mm, w1 = 0.8 mm, w2 = 0.75 mm. The whole unit cell dimension is 15 mm × 15 mm. Due to the symmetry of the structure, its responses to vertically and horizontally polarized incident waves are the same for planar applications. In this work, the vertical polarization has been chosen for simulations and measurements.A wideband radar absorber based on modified second-order Saltire cross structure and four H shape coupling additives have been designed, as shown in 11) and absorption of the absorber with various silicone thicknesses h, can be found in h = 2 mm. In this case, the optimized absorber has a wideband effective absorption (above 90% absorption) from 8 GHz to 19 GHz, which covers both X and Ku bands. The absolute bandwidth is 11 GHz and fractional bandwidth is 81.5%. It can be found that the absorption band extends to lower frequency with thicker substrate, whereas thinner substrate provides better absorption at higher frequency band. Trade-off can be achieved through optimization. In this work, the thickness of the optimized absorber is less than 0.1λo at central frequency (13.5 GHz), which is thinner in comparison with similar worksThe simulated reflection coefficient  and from 13 GHz to 20 GHz (higher band) to experimentally examine the RCS of the printed graphene wideband absorbers. In Ω/sq). As it can be seen in the insertion of Ω/sq. However, it varies in different sections due to the inconsistency of thickness in the manually sputtered graphene nano-flakes layer. To further examine the cause of this discrepancy, simulations on the influence of sheet resistance variation of graphene nano-flakes layers were carried out. As it can be seen in Ω/sq to 30 Ω/sq, the lower band absorption reduces. As the printed graphene pattern was designed for Ω/sq, the larger the differences on sheet resistance, the more deterioration on lower band performance will be. From this analysis, it can be concluded that the differences on simulation and measured results was mainly caused by the non-uniformity of sheet resistance distribution of the printed graphene patterns.The same measuring procedure for the planar absorber has been conducted in the higher frequency band from 13 GHz to 20 GHz, and the results are shown in For radar absorbers, it would be highly desirable that the absorbers can be mechanically flexible and conformable so to cover differently shaped objects. For this purpose, flexibility and conformability of the printed graphene nano-flakes radar absorber has been investigated. The measurement setup for the conformable case has been explained in We have applied printed graphene nano-flakes to radar absorbers for RCS reduction in this work. A wideband absorber has been designed, which consists of patterned printed graphene nano-flakes layer, silicone substrate and backed metal. The absorber is fabricated with stencil printing method and the graphene nano-flakes ink are sputtered on silicone layer to form patterns through stencil with the help of air blaster. The absorber has been measured in anechoic chamber and experimentally demonstrated to provide effective absorption from 10.4 GHz to 19.7 GHz and a fractional bandwidth of 61.8%, with thickness only around 2 mm. The printed graphene nano-flakes absorber is mechanically flexible and its performance when bended to cover a metal cylinder have been measured to characterize its conformability. The measurement results show that only 3.6% reduction of the effective absorption bandwidth due to bending. The maintained wideband absorption reveals the potential applications of the printed graphene nano-flakes radar absorber in providing RCS reduction for objects of various shapes. In conclusion, this work has demonstrated unambiguously that printed graphene nano-flakes ink can be used not only for wideband radar absorption, but also flexibility and conformability.3 g expanded graphite (EG) was added into a mixture solution of 15 ml ethylene glycol and 45 ml ethanol. Non-ionic polymer-type surfactant was added to improve the dispersion of graphene nano-flakes. After stirring for 20 min, the dispersion was treated with sonication at 820 W with a cooling system for 24 hours. After that, the dispersion was heated on a hot plate with continuous stirring to remove the ethanol, yielding a final viscous ink of about 17% w/w solid in ethylene glycol, as seen in To make patterns on silicone, a stencil was fabricated with industrial laser cutting technology . As seen in All data generated or analysed during this study are included in this published article and its How to cite this article: Huang, X. et al. Experimental Demonstration of Printed Graphene Nano-flakes Enabled Flexible and Conformable Wideband Radar Absorbers. Sci. Rep.6, 38197; doi: 10.1038/srep38197 (2016).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Individuals with autism spectrum disorder (ASD), including those who otherwise require less support, face severe difficulties in everyday social interactions. Research in this area has primarily focused on identifying the cognitive and neurological differences that contribute to these social impairments, but social interaction by definition involves more than one person and social difficulties may arise not just from people with ASD themselves, but also from the perceptions, judgments, and social decisions made by those around them. Here, across three studies, we find that first impressions of individuals with ASD made from thin slices of real-world social behavior by typically-developing observers are not only far less favorable across a range of trait judgments compared to controls, but also are associated with reduced intentions to pursue social interaction. These patterns are remarkably robust, occur within seconds, do not change with increased exposure, and persist across both child and adult age groups. However, these biases disappear when impressions are based on conversational content lacking audio-visual cues, suggesting that style, not substance, drives negative impressions of ASD. Collectively, these findings advocate for a broader perspective of social difficulties in ASD that considers both the individual’s impairments and the biases of potential social partners. Individuals with autism spectrum disorder (ASD) are characterized by impairments in social interaction that contribute to broad social disabilities and poor functional outcomesResearchers have long investigated the cognitive and neural differences that contribute to social interaction impairments in ASD89818Such relational factors are emphasized in the social model of disability20How people respond to unfamiliar individuals prior to social interaction is governed in large part by first impressions, which are near instantaneous judgments of personality and character traits based upon “thin slices” of informationThe present study evaluates first impressions of children and adults with ASD by unfamiliar observers, including same-age peers, and examines their relation to subsequent intentions for social interaction. Unlike prior studies that have assessed attitudes towards autism using survey methods282931p = 0.786) and full-scale IQ on the WASI . ASD diagnoses were confirmed by a certified clinician using the Autism Diagnostic Observation ScheduleForty adults  served as stimulus participants. The stimulus groups were matched on gender , and were comparable on both age  for each of the 40 stimulus participants. Each stimulus was rated one at a time on ten items using a four-point scale (0–3). Six items related to traits that are reliably perceived when forming first impressions: attractiveness, awkwardness, intelligence, likeability, trustworthiness, and dominance/submissiveness1428p < 0.001, η2 = 0.555) found ASD stimulus participants to be rated less favorably overall  than TD stimulus participants . Significant interactions occurred between: group and modality  = 9.14, p < 0.001, η2 = 0.194); group and rating  = 17.57,  < 0.001, η2 = 0.316); and a three-way interaction between group, rating, and modality  = 3.10, p < 0.001, η2 = 0.076). Follow-up pairwise comparisons explored patterns of group differences on each interaction, with Bonferroni correction to control for multiple comparisons and Greenhouse-Geisser correction when Mauchly’s test indicated that the assumption of sphericity had been violated.We conducted a 2 (ASD vs. TD stimulus group) by 5  by 10 (rating) mixed-model ANOVA. A significant main effect of stimulus group  = 47.33, p = 0.32, d = 0.29). The ASD group was rated significantly less favorably in the audiovisual modality  than in than the Audio  and Transcript  modalities. For the group by rating interaction , intelligence t(38) = 0.89, p = 0.38, d = 0.26), and willingness to live nearby t(38) = 2.03, p = 0.05, d = 0.46), with the largest effect size occurring for the rating of awkwardness (t(38) = 9.37, p < 0.001, 95% CI , d = 2.96). For the significant three-way interaction between group, rating, and modality, visual modalities  produced less favorable ratings for the ASD stimulus participants than the Audio and Transcript modalities for ratings of awkwardness  = 11.78, p < 0.001, η2 = 0.383), attractiveness  = 19.78, p < 0.001, η2 = 0.510), intent to hangout  = 10.16, p < 0.001, η2 = 0.348) and intent to talk to  = 6.65, p < 0.001, η2 = 0.259). In contrast, ratings for the TD group were generally consistent across all modalities, with significant differences only emerging for the silent video modality producing more favorable ratings than the transcript modality for intelligence  = 7.43, p = 0.002, η2 = 0.281), likeability  = 5.54, p = 0.011, η2 = 0.226) and intent to talk to  = 4.45, p = 0.02, η2 = 0.190).For the group by modality interaction see , ASD stition see , ASD stirs>.59, ps < 0.01) between ratings of trustworthiness, likability, and intelligence and each behavioral intent item. One discrepant pattern between groups did emerge, however: the ASD, but not TD, stimulus participants demonstrated significant negative relationships between awkwardness ratings and the raters’ intent to talk to  and to hang out with . Finally, mean ratings across the items did not differ between male and female stimulus participants (t(38) = 7.46, p = 0.17, Male: M = 2.41, SD = 0.21; Female: M = 2.28, SD = 0.20, 95% CI , d = 0.63).We also explored relationships between individual character and behavioral intent items averaged across modalities see . Both grp = 0.96) and full-scale IQ  = 1.12, p = 0.27). Thirty-seven undergraduate students  served as raters and provided informed consent. They also received class credit for their participation. The Institutional Review Board of Indiana University approved this study and all methods were performed in accordance with the relevant guidelines and regulations.A total of 12 adults with ASD  and 16 TD participants  served as stimulus participants. ASD diagnoses were confirmed by the ADOS-2 (Module 4) administered and scored by research reliable personnel. Groups were matched on age  = 0.05, Stimulus participants sat directly across from an experimenter while responding to a brief set of open-ended casual questions . The experimenter was instructed to respond appropriately and attempt to engage the participant in a natural dialogue. All participants were familiar with the experimenter from having participated in previous studies in the laboratory. The experimenter recorded video using wearable point-of-view video recording glasses , thus providing a direct first-person point of view of the social interaction. All but five participants also completed the UCLA Loneliness Scale.We used MATLAB  to randomly select 10 still frames  from each video to be used as stimuli. Images were only excluded if the subject was not near the middle of the frame or if the image was blurry (both due to head movement of the experimenter), or if the stimulus participant’s eyes were closed. These images were then cropped to eliminate some of the background and show the person from approximately their torso and above.Raters were instructed that they would be viewing a variety of photographs of individuals taken during a typical social interaction, and their task was to make various judgments based on these images. Each rater completed 3 experimental blocks, with each block corresponding to a different rating question: (1) “How socially awkward is this person?” (2) “How approachable is this person?” (3) “Would I see myself being friends with person?” Stimuli within each block were randomized, and each stimulus participant was seen a total of 10 times per block. Male raters only rated male stimulus participants (190 stimuli per block), and female raters only rated female stimulus participants (90 stimuli per block).Ratings were made using a non-graduated slider, with ends labeled and representing the extremes of the judgment . These extremes were quantified as ‘0’ and ‘1’, with intermediate values falling in between this range corresponding to the location of the sliding bar. Participant responses were stored with a mouse click, and the next stimulus was shown after a 1 second inter-trial interval. There were no time constraints for responding. The experiment was presented using MATLAB and Psychtoolbox (PTB3)p < 0.001; η2 = 0.457] and group , but no group x rating category interaction . [Note that scores for the awkwardness were reverse scored so that higher scores reflect positive judgments for all questions.] Across all three rating categories, individuals with ASD were rated less favorably than TD controls (Awkwardness: t(26) = 4.51, p < 0.001, 95% CI , d = 1.68); Approachability: t(26) = 4.57, p < 0.001, CI , d = 1.71; Likelihood of being friends: t(26) = 3.91, p < 0.001, 95% CI , d = 1.50)  x 2 (group) repeated measures ANOVA revealed a main effect of rating category , group , or group x rating category interaction . Furthermore, for all ASD and TD stimulus participants, slopes were not different from zero (6 one-sample t-tests), demonstrating that ratings were reliable over repeated exposure [all ps > 0.11]  x 2 (group) repeated measures ANOVA as above, but with slope as the dependent variable. There was no effect of rating category  see . Finallyp = >0.250), IQ on the Leiterp = 0.200), or receptive vocabulary on the PPVTp = 0.189). ASD diagnosis was confirmed by trained clinicians using the ADOS14 boys, seven with ASD and seven TD controls, served as stimulus participants. The groups did not differ significantly on age  = 104.99, p < 0.001, η2 = 0.52) and a main effect for question  = 46.32, p < 0.001, η2 = 0.32, as well as a significant interaction between question and stimulus participant group F = 4.98, p = 0.001, η2 = 0.05). Ratings can be found in Scores for two items (“awkwardness” and “spending time by themselves”) were reversed scored in all analyses so that higher ratings reflect more positive judgments for all items. Data from adult raters were analyzed first. We conducted a 2 (stimulus producer group: ASD vs TD) by 5 (question) repeated measures ANOVA, which revealed a main effect for stimulus participant group (t(97) = −7.59, p < 0.001, 95% CI , d = 0.95), less likely to have a lot of friends (t(97) = 9.85, p < 0.001, 95% CI , d = 1.06), less likely to get along well with others (t(97) = 7.76, p < 0.001, 95% CI , d = 0.69), more likely to spend time by themselves (t(97) = 7.65, p < 001, 95% CI , d = 0.80), and were judged to be significantly more awkward than the TD controls in the videos (t(97) = 10.05, p < 0.001, 95% CI , d = 1.03). Lower awkwardness ratings significantly correlated with greater perceived likelihood of starting a conversation with others , having a lot of friends , getting along well with others , and with the perceived likelihood of spending a lot of time alone . These relationships remain significant when examining stimulus participant groups separately: likelihood of starting a conversation with others , having a lot of friends , getting along well with others , and perceived likelihood of spending a lot of time alone .We conducted follow-up pairwise t-tests to compare item responses between groups, using Bonferroni adjusted alpha levels of.01 per test to adjust for multiple comparisons. Results show that children with ASD were rated as significantly less likely to start a conversation with others  = 15.97, p < 0.001, η2 = 0.333), but no main effect of question  = 0.12, p = 0.887, η2 = 0.004), and no question by stimulus participant group interaction  = 1.04, p < 0.36, η2 = 0.032). Follow-up pairwise t-tests using Bonferroni adjusted alpha levels of.0167 per test compared responses to each question between stimulus participant groups and show that children with ASD were rated by adolescents as significantly less likely to get along well with others (t(32) = 4.69, p < 0.001, 95% CI , d = 0.39) and more likely to spend time by themselves (t(32) = 3.75, p = 0.001, 95% CI , d = 0.32). Awkwardness, however, did not reach significance (t(32) = 1.94, p = 0.06, 95% CI , d = 0.25).To examine whether patterns held when raters were similar in age to the stimulus participants, a 2 (stimulus participant group: ASD vs TD) by 3 (question) repeated measures ANOVA was conducted using a sample of adolescent raters. We found a main effect for stimulus participant group  and longer (10 s) glimpses of social behavior, and did not change with repeated exposure. Further, because these impressions were associated with reduced intentions to socially engage by observers, they may reflect a previously under-recognized contributor to the reduced quantity and quality of social interaction experienced by individuals with ASD.Our findings show that negative first impressions of adults with ASD occurred only when audio and/or visual information was present, and not when the transcript of their speech content was evaluated (Study 1). This discrepancy suggests that social presentation style rather than the substantive content of social speech drove negative impression formation of individuals with ASD. Supporting this conclusion, a static image was sufficient for generating negative first impressions of those with ASD and including additional information, such as body movement or voice, did not worsen them further. In contrast, first impressions of TD controls improved with the addition of a visual information, suggesting that unlike the ASD group, visual cues helped rather than hurt the impressions they made on observers. We also determined that negative impressions extended beyond perceived social competence to judgments of likeability (reduced), attractiveness (reduced), and submissiveness (increased) (Study 1). However, negative impressions did not occur for all evaluated traits, with the two groups not differing on ratings of perceived intelligence or trustworthiness. The lack of group differences on these traits suggest that the social presentation differences in the ASD group may lead to more negative evaluations of traits associated with social appeal and approach behaviors , than those associated with competence (intelligence) and character (trustworthiness).We also demonstrate that negative impressions remain stable across multiple thin-slice judgments. A series of randomly selected static images of college-aged individuals with ASD collected from a first-person perspective during social interaction were consistently rated as less approachable and more awkward than matched controls, with observers indicating a lower likelihood of being friends with members of the ASD group (Study 2). These ratings were stable across ten exposures of different randomly-selected images of each individual, suggesting that the negative impressions of the ASD group were not driven by poorer or non-representative image capture or by sequence effects, but rather by reliable differences in social presentation in ASD leading to consistent negative evaluation. This finding of negative evaluations of individuals with ASD is also emphasized by the consistency of results across all three studies, which include static and dynamic stimuli, as well as representations of different age groups.Adult and school-aged observers also report negative perceptions of adolescents with ASD (Study 3), indicating that negative first impressions persist even when observers are similar in age to those being evaluated. The extension to school-aged children is important given that individuals with ASD generally receive the greatest amount of social skills intervention during this developmental periodFindings across the three independent studies were remarkably consistent despite using distinct samples and methods. Taken together, they offer strong evidence that the social presentations of individuals with ASD, particularly their non-verbal cues, including prosody, facial expressions, and body posture, are perceived less favorably and are associated with reluctance on the part of observers to pursue social engagement. This is particularly important given that individuals with ASD self-reported much greater feelings of loneliness than controls (Study 2). This is consistent with prior research indicating that individuals with ASD do not differ from their TD peers in their desire for relationshipsIt is also important to explore specific components of visual and/or auditory presentation that may lead to negative impressions of young adults with ASD . Several of the stimuli used across the three studies were videos and there is some evidence in the literature that the movement patterns of individuals with ASD are atypical and may represent a salient cue of awkwardness or difference to TD observers4646Recent studies also suggest the presence of autism-specific dysmorphology, specifically related to distances between facial featuresThe consistency of findings across these studies using different methodologies and stimulus types indicates that the foundation of these negative perceptions is complex and difficult to isolate. If our goal is to improve social interactions for individuals with ASD, it may therefore be equally important to educate others to be more aware and accepting of social presentation differences, rather than trying to change the many interwoven factors of self-presentation that mark the expressions of individuals with ASD as atypical. Given the social cognitive difficulties in perspective taking associated with autismThe studies reported here should be viewed in the context of several limitations. Although the real-world social presentations used in each study provided a more naturalistic portrayal of actual social behavior in ASD compared to previous work using actors or vignettes, they may not fully reflect how impression formation occurs during live social interaction. We only included explicit judgments made of those with and without ASD. In addition to what participants indicate explicitly, their biases may also play out in more implicit ways. Future studies may seek to address whether implicit biases towards those with ASD parallel the more explicit findings reported here. Further, all participants with ASD in this study were intellectually-capable, and findings may not generalize to cognitively impaired populations. Additionally, while ratings did not differ for male and female stimulus participants in studies 1 and 2, sample sizes of females were small and future studies should examine whether patterns differ by gender. Finally, these studies present only group-wise comparisons and do not address individual differences among those with ASD, nor whether individual characteristics of the raters  affect the results reported here.These limitations notwithstanding, the current project provides convergent evidence across three independent studies that first impressions of individuals with ASD are significantly less favorable than those of matched TD controls, and are associated with greater reluctance on the part of observers to pursue social engagement. The data demonstrate that negative impressions are formed across age groups and based on a range of features, including visual, auditory, dynamic, and static cues, indicating that these impressions are not context- or stimulus-dependent and are likely to persist across a range of real-world social situations. Taken together, these findings suggest that social interaction difficulties in ASD are not solely an individual impairment but also a relational one, and consideration of both of these factors is necessary for a full understanding of social impairment in ASD. The reluctance of TD individuals to engage in social interactions with their ASD peers further limits the opportunities for individuals with ASD to practice their already fragile social skills. This can have a significant negative impact on the ability of socially aware and socially interested individuals with ASD to improve their social communication abilities and work toward more successful social integration. Therefore, intervention and education approaches that target both those with ASD as well as their TD peers may offer a more comprehensive approach for improving social and functional outcomes in autism.How to cite this article: Sasson, N. J. et al. Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments. Sci. Rep.6, 40700; doi: 10.1038/srep40700 (2016).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


LCIG; carbidopa‐levodopa enteral suspension in the United States), delivered via percutaneous gastrojejunostomy (PEG‐J) and titrated in the inpatient setting, is an established treatment option for advanced Parkinson's disease (PD) patients with motor fluctuations. However, long‐term prospective data on the efficacy of LCIG on non‐motor symptoms and the safety of outpatient titration are limited.Levodopa‐carbidopa intestinal gel  total score  and 6 of the NMSS domain scores  at week 12. These reductions were maintained at week 60 with the exception of the urinary domain. “Off” time  and “On” time without troublesome dyskinesia  were improved at week 60. Adverse events (AEs) were reported in 37 (95%) patients.Thirty‐nine patients were enrolled in the study and 28 patients completed the treatment. A majority of patients (54%) completed outpatient titration within the first week of LCIG treatment led to reductions in non‐motor symptom burden and motor fluctuations in advanced PD patients. The safety profile was consistent with previous studies that used inpatient titration and outpatient titration did not appear to pose additional risk. Levodopa‐carbidopa is the most efficacious drug treatment for Parkinson's disease (PD). However, disease progression and prolonged use of standard oral formulations are associated with the development of disabling motor complications that are refractory to medication changes in a majority of levodopa‐carbidopa‐treated PD patients. Fluctuations in response are driven primarily by non‐physiologic pulsatile stimulation of striatal dopamine receptors, which in turn are related partly to the progressive degeneration of dopaminergic neurons, the short half‐life of levodopa, and increasingly irregular gastric emptying.Levodopa‐carbidopa intestinal gel  provides continuous intestinal levodopa infusion via percutaneous endoscopic gastrojejunostomy (PEG‐J), and reduces fluctuations in levodopa plasma concentrations.In the previous phase 3 studies participants were hospitalized for up to 14 days for PEG‐J placement and LCIG dose titration; however, current clinical practice does not require routine hospitalization for these procedures. In this open‐label study, PEG‐J placement was performed as per clinical practice and LCIG dose titration was completed as an outpatient procedure.http://www.clinicaltrials.gov: NCT01736176). The study was conducted at 12 specialized movement disorder centers in the United States. The study protocol was approved by the institutional review board/ethics committee at each study center and all patients provided written informed consent.The efficacy of LCIG for the treatment of non‐motor symptoms and safety of outpatient titration were assessed in advanced PD patients experiencing motor fluctuations despite optimized medical therapy in this open‐label, phase 3b, 60‐week study , PEG‐J placement, outpatient LCIG titration, a 12‐week primary LCIG treatment period, and a 48‐week, long‐term LCIG‐treatment maintenance period . The PEG‐J tube placement procedure occurred on study day 1 (D1) by a gastroenterologist, surgeon, or interventional radiologist as an outpatient procedure. At the discretion of the investigator or the physician, patients could require in‐patient (24–48 hours) observation.LCIG initiation and outpatient dose titration began within 5 days of PEG‐J placement; outpatient summaries were based on data observed by clinical nurse educators rather than study investigators. LCIG was administered during waking hours; a morning dose/bolus was followed by continuous infusion for approximately 16 hours. The LCIG morning dose volume, continuous infusion rate, and rescue dose volume were programmed on the infusion pump at clinic visits. Pump settings were individually titrated based on clinical effect throughout the study. The LCIG dose was considered optimized when the programmed pump settings remained unchanged for 7 consecutive days. Patients controlled the daily start and stop times of infusions and could self‐administer additional rescue doses, if clinically indicated. Patients who completed their week 60 study visit before LCIG was commercially available to them had the option to remain in the study with clinic visits every 12 weeks.The primary efficacy outcome was the mean change in Non‐Motor Symptom Scale (NMSS) total score from baseline to week 12. The NMSS assesses non‐motor symptoms in PD, is obtained through patient interview, and contains 30 questions (grouped into 9 domains) that are scored with respect to severity. Total non‐motor symptom burden is defined as mild , moderate (16–40), severe (41–65), and very severe (≥66).Treatment‐emergent adverse events (AEs) were documented throughout the study and included all AEs with onset on or after the date of PEG placement and within 30 days of the end of LCIG treatment. AEs were coded using the Medical Dictionary for Regulatory Activities 18.1 (MedDRA)Efficacy analyses included all patients who received at least 1 LCIG infusion and had baseline and post‐baseline observations for at least one efficacy or health outcome measure (N = 38). Safety summaries included all patients who underwent PEG‐J procedure (N = 39). Baseline was defined as the last non‐missing observation that was on or before the date of the patient's first oral study drug dose (efficacy) or before the date/time of the PEG‐J procedure (safety). Final visit was defined as the last non‐missing observation that was ≤1 day after last LCIG infusion (efficacy) or end of PEG‐J exposure (safety). For efficacy analyses, change from baseline was evaluated with a repeated measures model that included fixed effects of study site and visit, with baseline score as a covariate, and the baseline‐by‐visit interaction (reported as the least‐squares mean change ± standard error). PD Diary data were normalized to a 16‐hour waking day and averaged for the 3 days prior to each visit. Only diaries with ≥12 hours of awake‐time were included in the analysis. “On” time without troublesome dyskinesia (TSD) was defined as the sum of “On” time without dyskinesia and “On” time with non‐TSD.Of the 39 patients enrolled, 38 had successful PEG‐J placement and received LCIG infusion and 28 (72%) completed the study Fig. B. ElevenFollowing PEG‐J placement procedure, the mean ± SD time to patient discharge from the hospital/clinic was 20.4 ± 14.6 hours (N = 30); 63% (n/N = 19/30) of patients were discharged from the hospital within 24 hours. During outpatient titration, 66% (n = 25) of patients received their first LCIG dose within 24 hours of PEG‐J placement; 90% (n = 34) of patients had LCIG initiated within 48 hours. A majority of patients  reached an optimized dose within the first week of LCIG infusion and only 2 (5.4%) patients required more than 2 weeks to achieve dose optimization. One patient discontinued treatment due to a non‐procedure/device‐related AE with onset during the first 4 weeks of LCIG infusion and 35 (92%) patients were still receiving LCIG infusions at the 12‐week primary endpoint. The mean ± SD time of patient exposure to LCIG was 427.2 ± 188.7 days . The mean ± SD time of patient exposure to the LCIG delivery device was 427.5 ± 190.8 days . Sixteen (42%) patients received concomitant anti‐PD medication during the 60‐week treatment period and 7 (18%) of these patients received non‐levodopa medication. The most common concomitant, non‐levodopa, anti‐PD medication during the 60‐week treatment phase was entacapone .P < 0.001) . The NMSS urinary domain was significantly reduced compared to baseline at week 12 .On average, patients had severe non‐motor symptom burden at baseline .01) Fig. A. NMSS t01) Fig. . For patP = 0.004). PD Diary asleep‐time was not significantly changed at week 60  patients experienced any AE and 35 (90%) patients experienced an AE assessed by the investigator as possibly related to LCIG (Table % patientPolyneuropathy‐related AEs were reported in 3 (8%) patients, were mild in severity, and included loss of proprioception (n = 1), peripheral neuropathy alone (n = 1), and peripheral neuropathy with peripheral sensory neuropathy (n = 1). Prior to LCIG initiation, patients reporting polyneuropathy‐related AEs were receiving between 1700 and 2400 mg daily levodopa dose . The reports of peripheral neuropathy alone and peripheral neuropathy with peripheral sensory neuropathy were deemed by the investigators to have a possible relationship to study drug. The patient who experienced a loss of proprioception had a history of peripheral nerve disorder and vitamin B12 deficiency; the event was determined by the investigator to have no relationship to study drug or oral carbidopa/levodopa immediate release. No polyneuropathy‐related AEs led to premature discontinuation of LCIG. Other AEs of special interest included GI and GI procedure‐related events , weight loss events , and respiratory tract aspiration events .During weeks 1–4, 22 56%) patients experienced a GI‐related AE and 21 (54%) patients experienced a non‐GI related AE (Table 6% patienAmong the 5 patients (13%) who discontinued study drug due to AE, 4 discontinued due to events considered by the investigator to be possibly related to LCIG. One patient with a baseline Mini Mental State Examination score of 24 discontinued study drug on day 72 due to cognitive disorder with onset on treatment day 3 that remained unresolved; 1 patient discontinued due to stoma site pain with onset on day 130 that resolved 8 days later; 1 patient discontinued due to a stoma site infection with onset on day 255 that resolved 79 days later; 1 patient discontinued due to the onset of pneumonia on day 255 that lasted for 15 days; another patient discontinued study drug on day 178 due to events of congestive cardiac failure, acute respiratory failure, and aspiration pneumonia following spinal surgery. These events were considered to be unrelated to LCIG by the study investigator and resulted in the patient's death on day 179.This open‐label, phase 3b study evaluated the long‐term efficacy of LCIG for the treatment of non‐motor symptoms and the safety of outpatient titration in advanced PD patients. Continuous infusion of LCIG led to significant and clinically meaningfulIn addition to the observed non‐motor symptom improvements, LCIG treatment also led to a significant and sustained improvement in HRQoL. The improvements in non‐motor symptoms and HRQoL are consistent with previously published long‐term data on LCIG, including 12‐month data from the observational GLORIA study, which reported non‐motor symptom and HRQoL improvements in PD patients treated with LCIG during routine care.Reduced non‐motor symptom burden occurred alongside sustained improvements in motor symptoms, including a significant and clinically meaningful decrease in “Off” time through week 60.A secondary objective of this study was to evaluate the safety of outpatient LCIG titration, an approach that is more reflective of current clinical practice. The data indicate the success of outpatient titration, with 90% of patients beginning LCIG infusion within the first 48 hours after PEG‐J placement and a majority of patients reaching LCIG dose optimization within one week of their first LCIG infusion. The safety results also suggest that outpatient LCIG titration was generally well tolerated. The percentage of patients in the current study that experienced an AE during the first 4‐weeks following PEG‐J placement (71.8%) was lower than previously reported in other phase 3 LCIG studies that utilized inpatient titration, including a 12‐week, double‐blind, placebo‐controlled, double‐dummy clinical trial (% of patients with AE during weeks 1–4 = 86.5%) and a 12‐month open label study (% of patients with AE during weeks 1–4 = 78.4%).The safety results over the course of the entire study also speak to the general success of outpatient titration. While the discontinuation rate (28%) and rate of discontinuations due to AE (13%) over the entire study course were higher than previous phase 3 studies (overall phase 3 discontinuation rate = 17%,Limitations of this study include its open‐label design and lack of a control group, which is important to consider, as treatment‐related improvements in non‐motor symptoms have been associated with a strong placebo effect in recent literature.In summary, LCIG demonstrated sustained and clinically meaningful reductions in non‐motor symptom burden and improvements in quality of life in advanced PD patients with motor fluctuations over a 60‐week treatment period. Also, LCIG was generally well tolerated, supporting the established profile of LCIG and the safety of outpatient titration.1. Study Concept/design; 2. Data Acquisition; 3. Statistical Analysis; 4. Data Interpretation.D.G.S: 1, 2, 4R.L.R.: 2, 4J.T.S.: 2, 4M.L.: 2, 4S.E.: 1, 2, 4K.C.: 1, 2, 4M.F.: 2, 4C.H.: 1, 2, 3, 4K.S.: 4Y.J.J.: 4J.B.: 1, 2, 4Ethical Compliance Statement: We, the authors, confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.Funding Sources and Conflict of Interest: Study‐related disclosures: D.G.S., R.L.R., J.T.S., and M.L. were study investigators. D.G.S., J.T.S. were paid consultants to AbbVie for study design and medical/scientific advice. J.T.S. received research support from AbbVie. S.E. and K.C. are former AbbVie employees. M.F., C.H., K.S., Y.J.J., and J.B. are employees of AbbVie and own AbbVie stock/stock options.This work was funded by AbbVie Inc. AbbVie participated in the study design, research, data collection, analysis, and interpretation of data, writing, reviewing, and approving the publication. Medical writing support was provided by Amy M. Spiegel of AbbVie Inc.Financial disclosures from previous 12 months: D.G.S. is a member of the faculty of the University of Alabama at Birmingham and is supported by endowment and University funds. Dr. Standaert is an investigator in studies funded by Abbvie, Inc., the American Parkinson's Disease Association, The Michael J. Fox Foundation for Parkinson's Research, Alabama Department of Commerce, and NIH grants P01NS087997, P20NS087997, R25NS079188, P2CHD086851, and P30NS047466. He has a clinical practice and is compensated for these activities through the University of Alabama Health Services Foundation. In addition, since January 1, 2016 he has served as a consultant for or received honoraria from, Serina Therapeutics, Abbvie, Voyager Therapeutics, the Michael J. Fox Foundation for Parkinson's Research, The International Parkinson's Disease and Movement Disorder Society, the National Institutes of Health, The American Institute for Biological Sciences, Rush University, Huntsville Hospital, UCSD, Voyager Therapeutics, and he has received royalties for publications from McGraw Hill, Inc. R.L.R. has received research support from AbbVie Inc., Allergan, Auspex, Biotie Therapeutics, Dystonia Coalition, Huntington Study Group, Ipsen, Merz Pharmaceuticals, National Parkinson's Foundation, NIH/NINDS, Parkinson's Study Group, Chelsea, and Auspex, but has no owner interest in any pharmaceutical company; honoraria from PeerView Institute for Medical Education, Merz, Lundbeck, Chelsea, and the CME Meeting; and honoraria from AbbVie Inc. for speaking and educational symposium. J.T.S. has served as an advisor for AbbVie Inc. and Cynapsus Therapeutics Inc., a speaker for Teva and AbbVie Inc., and has received research support from AbbVie Inc., Biotie, NIH, Parkinson's Study Group and Veterans Administration. M.L. was a study investigator. M.F.F., C.H., K.S., Y.J.J., and J.B. are employees of AbbVie Inc and hold AbbVie Inc. stock and/or stock options. K.C. and S.E. are former employees of AbbVie Inc.


The purpose of this study was to describe the clinical implementation of a magnetic resonance image (MRI)‐based approach for adaptive intracavitary brachytherapy (ICBT) of cervix cancer patients. Patients were implanted with titanium tandem and colpostats. MR imaging was performed on a 1.5‐T Philips scanner using T2‐weighted (T2W), proton‐density weighted (PDW), and diffusion‐weighted (DW) imaging sequences. Apparent diffusion coefficient (ADC) maps were generated from the DW images. All images were fused. T2W images were used for the definition of organs at risk (OARs) and dose points. ADC maps in conjunction with T2W images were used for target delineation. PDW images were used for applicator definition. Forward treatment planning was performed using standard source distribution rules normalized to Point A. Point doses and dose‐volume parameters for the tumor and OARs were exported to an automated dose‐tracking application. Brachytherapy doses were adapted for tumor shrinkage and OAR variations during the course of therapy. The MRI‐based ICBT approach described here has been clinically implemented and is carried out for each brachytherapy fraction. Total procedure time from patient preparation to delivery of treatment is typically 2 hrs. Implementation of our technique for structure delineation, applicator definition, dose tracking, and adaptation is demonstrated using treated patient examples. Based on published recommendations and our clinical experience in the radiation treatment of cervix cancer patients, we have refined our standard approach to ICBT by 1) incorporating a multisequence MRI technique for improved visualization of the target, OARs, and applicator, and by 2) implementing dose adaptation by use of automated dose tracking tools.PACS numbers: 87.61.‐c, 87.53.Jw, 87.19.xj I.Three‐dimensional (3D)‐based intracavitary brachytherapy (ICBT) treatment planning for cervical cancer was implemented by the Groupe Européen de Curiethérapie‐European Society for Radiotherapy & Oncology (GEC‐ESTRO) working group, providing guidelines on the use of magnetic resonance imaging (MRI), primarily T2‐weighted (T2W) sequences, for target definition.At our institution, our standard approach for cervix cancer treatment — 25–28 fractions of positron emission tomography/computed tomography intensity‐modulated radiation therapy (PET/CT‐guided IMRT) combined with six weekly fractions of either film‐based or CT‐based high dose rate (HDR) ICBT using standard source distribution rules normalized to Point A—was performed from 1997–2008 and the results of this approach have been published previously.Here we describe the implementation of the multisequence MRI technique using T2W, DW, and PDW sequences for ICBT planning of cervix cancer patients. We also describe how we perform brachytherapy dose adaptation by tracking tumor volumes, tumor doses, and organs at risk (OAR) doses over the course of treatment, using an automated dose‐tracking application.II.A.All cervix cancer patients underwent FDG‐PET/CT simulation and were treated with IMRT, as described previously.B.TR=(3200−6500)ms,TE=100 ms, in‐plane resolution 0.1 cm, section thickness 0.5 cm, sagittal and axial acquisition planes), single‐shot DW echoplanar  at b values of 0 and 800 s/mm2, with diffusion gradients applied in all three directions, and PDW TSE (TR=(3000−6000) ms,TE=5.5 ms, in‐plane resolution 0.1 cm, section thickness 0.25 cm, sagittal acquisition planes), zero gap, foldover in the foot–head direction, 3–6 min per sequence. Imaging extents were set approximately from L4 to the ischial tuberosities in the craniocaudal direction, from the abdominal wall to the sacrum in the anterior–posterior direction, and were set to include the iliac crests in the transverse direction. Apparent diffusion coefficient (ADC) maps were generated from the DW‐MRI on the scanner console software in the following manner:SDW and So are signal intensities measured with and without diffusion‐weighted gradients, respectively, and the b value represents the diffusion factor.All patients reviewed an MRI safety questionnaire prior to each implant. Patients were implanted with a titanium tandem and colpostat applicator  in a semisterile environment. Either saline‐soaked gauze or saline‐filled balloon packing , was used to immobilize the implanted applicator within the patient, as well as provide distance between the applicator and adjacent OARs. Prior to imaging, 1 mg glucagon subcutaneous was also given to some patients to reduce bowel motion. Imaging was performed on a 1.5‐T MR scanner . Patients were positioned supine with body/pelvis phased array surface coils. MR scanning sequences included T2W turbo spin echo (TSE)  for contouring and isodose planning. Because the images were acquired in the same imaging session, the datasets upon import into the TPS were automatically registered based on their shared frame of reference and then manually verified using the applicator and surrounding anatomy. T2W images were utilized for contouring of OARs . Point A was defined relative to the applicator using the classical definition on the T2W images.D.3 of the OARs (D2cc). The doses were also normalized to their equivalent dose in 2 Gy fractions (EQD2).The Digital Imaging and Communications in Medicine (DICOM) standard radiation therapy (RT) dose, plan, and structure files were exported from the TPS to an automated dose tracking application referred to as the “HDR Dose Tool” . The HDR Dose Tool was used to create an HTML‐based spreadsheet which tracked external beam dose and brachytherapy dose, as well as cumulative doses.90 Gyαβ3 for bladder, 75 Gyαβ3 for rectum and sigmoid, as recommended by other adopters of MR‐based ICBT).> 50% reduction), and usually involved decreases in dwell weights of either 10% or 20%, while maintaining the V100 for that fraction ≥90%. Thus, weighting optimization yielded symmetric decreases of the dwell times with the dwell positions left intact. Even if the doses to OARs were greater than the respective thresholds in the first half of treatment, tumor dosage took priority, and the standard source distribution rules were followed for the first half of treatment.Dose adaptation may have been performed if the fractional D2cc to the OARs was greater than some threshold  and if the cumulative D2cc was greater than some threshold , D90 (>98 Gy), and Dmean (>260 Gy). Thus, to ensure these levels of local control with our dose adaptation approach, we will continue to define the GTV, as described here, as the sole target of interest, and will also consider these GTV dose metrics when performing dose adaptation.GEC‐ESTRO recommendations for ICBT planning consider the dose‐volume coverage of a GTV as well as of a high‐risk clinical target volume (HR‐CTV), whereas our technique only tracks the GTV, defined as gross tumor and not including any expansions or “gray” zones.V.Using our refined approach for MR‐based ICBT, we can perform multisequence imaging, automated dose tracking, and dose adaptation, and keep the time between implant and treatment delivery to within 2 hours. Although it may not be feasible for some clinics to implement all of the techniques as described here due to limited resources or established practices, we do believe that implementation of certain aspects of our technique will be of value to clinics performing MR‐based ICBT. Implementation of the multisequence MRI technique as described here will be of value for improved visualization of the target volume, critical structures, and applicator. Also, implementation of the dose tracking tools and dose adaptation technique by simply de‐escalating Point A‐based brachytherapy dose distributions will help balance target volume coverage with OAR sparing, without the need for more complex adaptation schemes.


Previously, transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) has resulted in improved performance in simple motor tasks. For a complex bimanual movement, studies using functional magnetic resonance imaging and transcranial magnetic stimulation indicated the involvement of the left dorsolateral prefrontal cortex (DLPFC) as well as left M1. Here we investigated the relative effect of up-regulating the cortical function in left DLPFC and left M1 with tDCS. Participants practised a complex bimanual task over four days while receiving either of five stimulation protocols: anodal tDCS applied over M1, anodal tDCS over DLPFC, sham tDCS over M1, sham tDCS over DLPFC, or no stimulation. Performance was measured at the start and end of each training day to make a distinction between acquisition and consolidation. Although task performance improved over days, no significant difference between stimulation protocols was observed, suggesting that anodal tDCS had little effect on learning the bimanual task regardless of the stimulation sites and learning phase (acquisition or consolidation). Interestingly, cognitive performance as well as corticomotor excitability did not change following stimulation. Accordingly, we found no evidence for behavioural or neurophysiological changes following tDCS over left M1 or left DLPFC in learning a complex bimanual task. Over the last decade, the effect of transcranial direct current stimulation (tDCS) on human motor performance and learning has been extensively investigated. A number of studies applying tDCS on the primary motor cortex M1) have shown positive effects on motor task performance and learning have sho2352While a variety of motor tasks have been shown to benefit from the application of tDCS, these tasks are predominantly simple motor tasks performed with a single effector3789101112A growing body of research has highlighted that a broader set of key brain regions are functionally involved in the execution of bimanual coordination1519212425262728930Moreover, previous research has shown differential effects for two components of the learning process: acquisition and consolidation. During acquisition, encoding of information takes place and improves performance, while learning can only take place following consolidation35In the current study, we aim to up-regulate the function of left DLPFC and left M1 with tDCS to enhance the learning of a complex bimanual coordination task while considering the two phases of learning, i.e., acquisition and consolidation. For this purpose participants were randomly assigned to one of five experimental groups: (1) anodal tDCS over left DLPFC (aDLPFC), (2) sham tDCS over left DLPFC (sDLPFC), (3) anodal tDCS over left M1 (aM1), (4) sham tDCS over left M1 (sM1), and (5) behavioural tasks without tDCS (BEHAV). This design allowed us to identify a potential placebo effect in the sham tDCS groups. To enable direct comparison with the studies described above17192017372939To this end, we hypothesized that the effect of tDCS over left DLPFC and left M1 on bimanual performance would depend on the task difficulty and the phase of learning. Specifically, we predicted that particularly the difficult task conditions would benefit from left DLPFC stimulation during acquisition as previous studies using our bimanual tracking task (BTT) showed extensive involvement of left DLPFC during this phase1719Performance on the bimanual tracking task was measured by the average target deviation during each trial. Only trials of the daily pre- and post-training measurements were included in analyses since performance on these trials are not mediated by feedback. Missing data of two independent sessions (one pre-measurement on day 2 and one pre-measurement on day 4 in two different subjects) due to technical problems were replaced by the mean target deviation of the other subjects belonging to the same group separately for each frequency ratio. BTT data were normalized to each individual baseline by dividing the target deviation of each trial by the average target deviation of the first session (pre-measurement on Day 1). To meet the assumption of normality, a log transformation was applied.general effects of tDCS on motor learning, we performed a mixed factorial ANOVA with factors Group , Time , difficulty level as reflected in Frequency Ratio  and all interactions. We observed a main effect of Time  = 32.15, p < 0.001, BF10 = 3.20 × 10151), indicating a general reduction of average target deviation over days of training. Also the main effect of Frequency Ratio (FR) was significant  = 34.67, p < 0.001, BF10 = 1.05 × 10155). Planned comparisons showed significant differences between isofrequency (FR 1:1) and multifrequency  trials  and not between multifrequency trials (0.05 < p < 0.84). As can be seen in 10 = 0.04), indicating no difference between stimulation groups over all time points. However, the interaction between Group and Time was significant  = 1.77, p = 0.02). −7. With respect to the first, this means that the data are 1/0.05 or 20 times more likely to occur under a model without-an effect of Group, rather than a model with it. In other words, the data provide strong evidence against the hypothesis that Group influences BTT performance according to the criteria by JeffreysTo study acquisition by performing a mixed factorial ANOVA on the difference between post- and pre-performance on each day (e.g. post-measurement Day 2 – pre-measurement Day 2) with factors Group, Time and FR. During acquisition, performance change was most pronounced at the first day and reduced over days  = 29.83, p < 0.001, BF10 = 4.27 × 1035). No significant difference between stimulation groups was observed  = 1.17, p = 0.33, BF10 = 0.02). In addition, we found evidence for a main effect of FR  = 8.22, p < 0.001, BF10 = 18.47), with a stronger reduction in target deviation in the multifrequency trials than in the isofrequency trials  and no difference between multifrequency trials (0.06 < p < 1). The difference between FRs decreased over days as indicated by a significant interaction between Time and FR  = 3.18, p = 0.001). Importantly, interactions including Group as a factor were not significant  = 1.45, p = 0.16; Group × FR: F = 1.18, p = 0.31; Group × Time × FR: F = 0.89, p = 0.64), indicating similar changes in performance were achieved by all the stimulation groups during acquisition. The main effects model with factors FR and Time was preferred to the main effects model with factors FR, Time, and Group by a Bayes factor of 0.03 and to the interaction model  by a Bayes factor of 0.88. The data provide very strong evidence in favour of the hypothesis of no effect of Group on acquisition of BTT (1/0.88 or 33.33 times more likely).Next we examined the effect of tDCS on consolidation was assessed by calculating differences between pre- and post-measurements of consecutive days (e.g. pre-measurement Day 2 – post-measurement Day 1) and we submitted the result as a dependent variable to a mixed factorial ANOVA with factors Group, Time and FR. Changes in target deviation during the consolidation interval did not differ significantly between groups  = 1.24, p = 0.30, BF10 = 0.03), between days  = 1.23, p = 0.30, BF10 = 0.06), and between frequency ratios  = 2.02, p = 0.11, BF10 = 0.02). Neither did we observe any significant interactions  = 1.23, p = 0.26; Group × FR: F = 1.63, p = 0.09; Time × FR: F = 1.06, p = 0.39; Group × Time × FR: F = 0.93, p = 0.59). In addition, no evidence for a difference between stimulation groups was found when looking at the first consolidation interval only  = 1.15, p = 0.34, BF10 = 0.11). The Bayes factors indicate that the data provide very strong evidence against the hypothesis that Group, Time or FR influences consolidation of BTT. In sum, these results suggested that the application of anodal tDCS did not have an additive effect on learning during consolidation phases, regardless of the stimulation site.The effect of To investigate the effect of tDCS on corticospinal excitability, we obtained MEP amplitudes in the right flexor carpi radialis (FCR) muscle before and after the training sessions in each session from subjects receiving anodal tDCS over left M1 (aM1) and sham tDCS over left M1 (sM1).10 = 0.35), neither did we observe a main effect of Time  = 0.27, p = 0.81, BF10 = 0.03) or an interaction between Group and Time  = 1.04, p = 0.37)  and Time  was performed. There was no significant main effect of Group  = 0.70, p = 0.41, BF = 0.37) . JZS Bayduring acquisition (by subtracting MEP amplitude obtained prior to the tDCS from MEP amplitude obtained after the tDCS) was found with a mixed factorial ANOVA  = 0.02, p = 0.89, BF10 = 0.27). In addition, no evidence for a main effect of Time was observed  = 0.27, p = 0.83, BF10 = 0.06), neither for the interaction of Time and Group  = 1.37, p = 0.26).No significant effect of Group on MEP amplitude change during the consolidation interval (by subtracting pre-MEP amplitude from the post-MEP amplitude of the previous day)  = 0.41, p = 0.53, BF10 = 0.31), which did not vary over Time  = 0.36, p = 0.74, BF10 = 0.07). Neither did we observe evidence for an interaction between Time and Group  = 0.73, p = 0.51). Overall, these results suggested that changes in corticospinal excitability following anodal tDCS was comparable with sham stimulation of left M1 and did not change, even after the simultaneous training and tDCS.Similarly, no Group differences were observed in MEP amplitude change Last, a Two Step cluster analysis on the ratios between pre- and post-MEP measurements of Day 1 was conducted4310 = 0.36), and a significant interaction between Group and Day was not observed (p = 0.39). In set shifting, a main effect of Group showed an approaching level significance . However, unlike our expectation, this was driven by the better performance in both stimulation groups  compared to the BEHAV group (75.4%). For response inhibition, no significant effects of Group  or Day by Group (p = 0.46) were found. In the 3-back task, no significant effects of Group and Group by Day were observed in percentage correct , percentage false positives , and reaction time . These results indicate no performance difference between anodal, sham and no tDCS over left DLPFC in any of the working memory tasks.Details of inferential statistics can be found in 10 = 0.12), sleep duration , alcohol intake  or caffeine intake  that could have confounded our results. We observed no significant difference in tDCS sensations between anodal and sham tDCS groups . However, a main effect of Group was observed for the starting time of sensations, with subjects reporting a later starting time in the sham tDCS groups . The main effect of Group did not reach significance level for the duration of sensations  and the subjective influence of sensations on performance .Only main findings are described here and additional details on data-analyses are reported in Both at the behavioural level and the neurophysiological level, we did not observe evidence for an effect of tDCS over left DLPFC or left M1 during acquisition or consolidation of a complex bimanual task, independent of task difficulty.We observed an overall learning effect on BTT performance (increased performance over training days). Performance was better in iso-frequency ratios compared to multi-frequency ratios. Our results correspond to earlier findings with this task1737Previous studies from our research group demonstrated that the bilateral DLPFC was highly involved in the acquisition of the same complex bimanual task17192426272845No overall differences in BTT performance were observed between the stimulation groups. Although the aM1 group showed higher performance after Day 3 relative to the other groups, this difference was not significant. We did not observe any evidence that anodal stimulation of left M1 specifically influenced acquisition or consolidation of learning a complex bimanual movement. Neither did we observe differences in the effect of left M1 stimulation between task difficulty levels. Similarly, at the neural level, we observed no effect of anodal tDCS over left M1 on corticospinal excitability measured with MEP amplitude. Our questionnaire results indicate that this cannot be related to an ineffective sham condition or sleep, alcohol, or caffeine consumption. This is in contrast to previous studies that have shown an increase in corticospinal excitability and behavioural performance in simple tasks after M1 stimulationPotentially, an explanation can be found in the tDCS protocol that we used. First, one could argue that applying tDCS during the task (online tDCS) instead of before the task (offline tDCS) has caused interference and abolished potential effects8234045465253Second, it is unlikely that ineffective blinding has confounded our results. We did not observe a significant difference in reported sensations following active and sham stimulation, which indicates subjects were blind to the stimulation condition. In addition, we tested whether a placebo effect of tDCS had obscured a difference between anodal and sham stimulation by including a behavioural group who received no stimulation. Because performance did not differ between the groups who received sham stimulation (sM1 and sDLPFC) and the behavioural group (BEHAV), a placebo effect explaining the lack of differences between groups is also unlikely.Third, we tried to reduce intra-subject variability due to the effects of circadian and metabolic rhythms by planning training sessions at the same time of the day at the four consecutive training days. Cluster analysis showed no indication for clusters of responders and non-responders in our MEP data.Fourth, potentially the cathode has induced stimulation in the right frontal cortex. However, to reduce the influence on brain areas under the cathode, we have used a cathodal electrode of 6 × 8.5 cm which is larger than the conventional size of 5 × 5 cm. Previously, it has been shown that increasing the size of the electrode turns the cathode effectively in an inactive electrodeBesides the tDCS protocol, one might argue that our healthy young subjects reached ceiling performance in the BTT, which eliminated room for improvement with tDCS. Therefore, stronger effects might have been found by testing and elderly population as there is some evidence to suggest that older adults have greater responsiveness to tDCS56836A more likely explanation for the limited effect of tDCS can be sought in network interactions. A recent TMS study from our groupIn sum, we investigated the effects of tDCS over left M1 and left DLPFC on learning of a complex bimanual task. We did not observe any additive learning effects of tDCS in acquisition or consolidation processes regardless of the task difficulty. Based on these results, we conclude that tDCS over left M1 and DLPFC has no beneficial effect on bimanual performance, at least with the parameters used and for the subjects sample tested in the current study. The potential reason is that the stimulation did not alter underlying mechanisms of bimanual performance including corticomotor system (following M1 stimulation) or cognitive function (following DLPFC stimulation). As such, we suggest that the effect of tDCS on behaviour may be limited to certain tasks and cohorts.Seventy-five university students participated in the study with an age range between 19 and 30 . Subjects were randomly assigned to one of five experimental groups, with 15 subjects in each group. No significant differences were observed between experimental groups in age or handedness see . A screeA schematic representation of the main procedure is given in We assessed working memory in the groups aDLPFC, sDLPFC and BEHAV to assess earlier findings on the effect of DLPFC stimulation on working memory. Two well-known working memory tasks were administered: a parametric Go/No-Go task and a 3-back task. To assess the short and long term effects of left DLPFC stimulation, subjects were assessed before the first tDCS session (pre-test on Day 1), after the last tDCS session (post-test on Day 4) and during the delayed post-measurement, one week later (Day 11).For the group who received stimulation over left M1 (sM1 and aM1), we assessed changes in corticospinal excitability using TMS. Corticospinal excitability was examined immediately before and following tDCS  by applying single-pulse TMS to the left M1 targeting right flexor carpi radialis (FCR), one of the prime mover muscles for the task we used. Excitability was also assessed on Day 11.et al., and Sisti et al.1717Subjects performed a complex bimanual tracking task in which they had to track a moving dot by rotating two dials with both hands simultaneously. A general description of the task is given below, additional details can be found in Beets On every training day (Day 1–4), subjects underwent a pre-measurement, training, and a post-measurement. Pre- and post-measurements consisted of 2 trials per condition  that were presented in one block and without feedback . The training phase consisted of 10 trials per condition . During training, conditions were presented in random order, a training scheme that has shown to be advantageous over blocked learning3761To confirm previous findings on the beneficial effect of tDCS over DLPFC on working memory, we included two tasks in our protocol that measured different components of working memory in groups aDLPFC, sDLPFC, and BEHAV. First, to measure sustained attention, response inhibition and set-shifting, we applied a parametric Go/No-Go task27At the start of each session, subjects reported the number of hours of sleep and the quality of sleep in the night proceeding the session on a 10-point scale. In addition, we asked for the number of units of alcohol and caffeine intake in the last 12 hours before the session.After the BTT training with tDCS, the stimulation groups  received a questionnaire about their perceived sensations during the stimulation. We asked to report the presence and severity of feelings of itchiness, tingling, headache, neck pain, scalp pain, burning, warmth/heat, pinching, iron taste, fatigue, concentration difficulties and acute mood changes. In addition, the onset and duration of these sensations was questioned and subjects were asked if the sensations influenced their performance.2) and a cathodal electrode of 6 by 8.5 cm (current density: 0.04 mA/cm2), which were placed in saline-soaked sponges. The choice for a bigger cathode was guided by the observation that increasing the size of the electrode turns the cathode in an effectively inactive electrodetDCS was delivered by a battery-driven constant current stimulation . The common safety guidelines were followed6465In aM1 and sM1, muscle activity was measured via EMG surface electrodes (Ag/AgCl) that were placed in belly-tendon montage over right FCR. A reference electrode was placed over the lateral epicondyle of the right arm. Raw signals were amplified with a gain of 1000 band-passed filtered (10–500 Hz) and sampled at 2000 Hz using a 16-bit analog to digital system .Single-pulse TMS was delivered with a standard figure of eight coil (70 mm loop diameter) connected to a Magstim 200 stimulator . The coil was positioned tangentially over scalp with the handle holding backward and laterally at 45° away from the mid-sagittal line. To maintain constant coil-positioning over the M1 hotspot of right FCR throughout the subsequent days of testing, the positioning and angles of the coil were monitored by a neuronavigation system . For navigation, a standard 3D anatomical MRI was used which was co-registered with the positions of the subject’s nasion, left ear, right ear and heap shape. After localization of the hotspot of the right FCR muscle in left M1, the position was marked with a semi-permanent marker for tDCS electrode placement. Subsequently, we measured resting motor threshold (rMT) on each day, prior to training and tDCS. The rMT is defined as the lowest intensity that elicits a motor evoked potential (MEP) of minimum peak-to-peak amplitude of 50 microvolts in 3 out of 5 consecutive trials. Before and after tDCS, we elicited MEPs by delivering 20 pulses at 130% of the individual rMT with an inter-stimulus interval of 5 seconds.BTT data were pre-processed in Labview  and MATLAB (Mathworks). A cluster analysis was performed in SPSS (IBM). All other statistical analyses were performed in RIn the TMS data, trials in which root mean square (RMS) EMG exceeded 15 μVHow to cite this article: Vancleef, K. et al. tDCS over left M1 or DLPFC does not improve learning of a bimanual coordination task. Sci. Rep.6, 35739; doi: 10.1038/srep35739 (2016).