In general, assessment tools for stigma in mental disorders such as attention deficit hyperactivity disorder (ADHD) are lacking. Moreover, misbeliefs and misconceptions about ADHD are common, in particular with regard to the adult form of ADHD. The aim of the present study was to develop a questionnaire measuring stigma in adults with ADHD and to demonstrate its sensitivity.A questionnaire initially containing 64 items associated with stigma in adults with ADHD was developed. A total number of 1261 respondents were included in the analyses. The psychometric properties were investigated on a sample of 1033 participants. The sensitivity of the questionnaire was explored on 228 participants consisting of teachers, physicians and control participants.Thirty-seven items were extracted due to exploratory factor analysis (EFA) and the internal consistency of items. Confirmatory factor analysis (CFA) revealed good psychometric properties of a 6-factor structure. Teachers and physicians differed significantly in their stigmatizing attitudes from control participants.The present data shed light on various dimensions of stigma in adult ADHD. Reliability and Social Functioning, Malingering and Misuse of Medication, Ability to Take Responsibility, Norm-violating and Externalizing Behavior, Consequences of Diagnostic Disclosure and Etiology represent critical aspects associated with stigmatization. The core symptoms of attention deficit hyperactivity disorder (ADHD), namely inattention, hyperactivity and impulsivity, result in highly externalized behaviors. This externalized behavior can be easily recognized by the environment and may induce misperceptions and misunderstandings about the condition. Moreover, public perceptions concerning ADHD have been shown to be foremost tied to the impression that ADHD is a disorder mainly seen in white middle-class boys suffering preeminent from symptoms of hyperactivity Empirical research on stigmatization revealed that not only physical deviances can set individuals apart and trigger stigmatization. Intrinsic characteristics of the individual such as behavioral deviance have also been found to provoke stigma Research demonstrated that stigmatization of individuals with ADHD has adverse consequences leading to diminished self-esteem and self-efficacious beliefs and ultimately a reduced quality of life Referring to courtesy-stigma, families, relatives or the social network of the target individual with ADHD can also be affected by stigma. For example, more than three-fourths of parents of children with ADHD reported to have encountered stigmatizing situations Considering the impact of stigmatization on the various facets of an individual’s life, the sporadic empirical investigation and the shortness of valid assessment tools measuring stigmatization in ADHD is surprising. This is in accordance with findings by Angermeyer and Dietrich disclosure concerns, negative self-image and concerns with public attitudes. The ASQ represents a valuable contribution in objectifying stigmatizing public beliefs about ADHD and demonstrates psychometric properties of distinct dimensions. However, since it is an adaptation of a disease-specific measure (HIV), no items specifically aiming at stigmatizing beliefs and perceptions related to ADHD are included. For example, the use of medication as a treatment for ADHD is controversially discussed in public and in media Only a few studies made use of survey responses, most likely because of a lack of psychometrically proven questionnaires for the measurement of stigmatization in ADHD. Kellison and colleagues In conclusion, despite stigmatization in ADHD being an important issue, there is a considerable lack of knowledge. Available measures primarily focus on children or do not distinguish between children, adolescents and adults with ADHD. Since it has only recently been acknowledged that ADHD is a condition that can continue from childhood to adulthood, it can be assumed that the public’s knowledge on ADHD in adults is more limited than their knowledge about childhood ADHD. Therefore studies on and measures for the assessment of stigmatization in adult ADHD are of particular significance. The aim of the present study is to enhance knowledge and conceptual clarity on stigmatization in adults with ADHD. A new questionnaire consisting of statements specifically designed to meet public beliefs and perceptions of ADHD in adulthood is developed. Psychometric properties of the questionnaire are explored and the sensitivity of the questionnaire is assessed by investigating differences between stigma responses of individuals with specific knowledge on ADHD  and individuals without specific knowledge.Data were obtained from a total of n = 1261 participants who completed a questionnaire measuring stigma responses towards adults with ADHD. Psychometric properties were explored on a sample of 1033 respondents. 439 of the 1033 respondents were first-year undergraduate psychology students of the University of Groningen, The Netherlands. The remaining participants were recruited via public announcements, word-of-mouth and through contacts of the researchers involved. Respondents’ age ranged from 17 to 79 years with a mean age of 31.3 years (SD = 14.8 years). Mean level of education was 16.4 years (SD = 1.2 years). The sample consisted of 66.0% female and 31.3% male participants with 2.7% missing information. Only 1% of the total sample claimed of never having heard about ADHD and 62.6% of participants stated to know an adult diagnosed with ADHD. On a scale of self-rated knowledge about ADHD ranging from 0  to 10 (expert knowledge), the average score was 4.5 (SD = 2.1). To perform an exploratory factor analysis (EFA) with a subsequent confirmatory factor analysis (CFA), the sample was split into two subsamples (i.e. Subsample 1 and Subsample 2). The allocation of participants to samples has been performed randomly by applying the option of a random selection of cases in SPSS 18. The two subsamples did not differ with regard to their descriptives .A further set of data (n = 228) was collected to demonstrate the sensitivity of the questionnaire by exploring stigma responses of a group of teachers and a group of physicians in comparison to a control group. 77 teachers and 74 physicians were recruited via public announcements, word-of-mouth and through contacts of the researchers involved. All teachers had successfully completed a university study program for teachers and were currently working as teachers for primary or secondary schools. All physicians completed successfully a medicine study program and were currently working as physicians in the health service. A control group (n = 77) was recruited with similar characteristics with regard to age, gender and educational level  .disclosure concerns, negative self-image and concerns with public attitudes. On the other hand, Haslam pathologizing, moralizing, medicalizing and psychologizing. A total of 64 items has been generated. Items were randomly arranged in the questionnaire to control for possible rang order effects. The questionnaire was constructed using a 6-point-Likert-scale with higher scores indicating higher stigma . Prior to the 64 items, eight inventorial questions were asked to obtain general background information including descriptive information of respondents . Information about participants’ self-rated knowledge concerning ADHD and their familiarity with adults with ADHD  was obtained at the end of the questionnaire. These questions were introduced at the end to prevent biased responses of participants to the 64 items.Based on (I) an extensive literature study on social perceptions, myths and stigma in ADHD, (II) the personal clinical experience with adults with ADHD of the researchers involved in this study and (III) patient interviews about their experiences, a deductive approach was applied for initial item generation All participants were invited to take part in the study on a voluntary basis. Participants received no reward for participation with the exception of undergraduate students who were credited toward a research requirement. The time to complete the questionnaire was estimated to take around twenty minutes. Participants were informed about the aim of the study and it was emphasized that all data will be analyzed anonymously. The study was approved by the ethics committee of the University of Groningen, The Netherlands.The study was approved by the Ethical Committee Psychology (ECP) affiliated to the University of Groningen, the Netherlands. Before participating, all participants were informed about the aims of the study. Participants were required to read and acknowledge an information sheet prior to completion of the questionnaire. Formal written consent was not sought for adult participants; submission of completed questionnaires was taken as implied consent. Since participants with an age of 17 years were included (n = 2), written informed consent was obtained from these participants as well as their parents prior to inclusion.Subsample 1 with a subsequent confirmatory factor analysis (CFA) on Subsample 2 in order to identify distinct factors of stigma in adults with ADHD. For EFA, a principal component analysis (PCA) was applied using orthogonal rotation (Varimax). Subsample 1 consisted of 516 participants. According to the classification proposed by Comrey and Lee very good” sample size.Exploratory factor analysis (EFA) was performed on Cronbach’s α was calculated for the total scale and the subscales (factors) of the questionnaire as a measure of internal consistency.Subsample 1, confirmatory factor analysis (CFA) was conducted on Sample 2 using the program LISREL 8.8 for Windows Subsample 2 (n = 517) exceeded the criterion of a minimum sample size of 200 respondents for CFA considerably To replicate the proposed factor structure model by the EFA on The factor structure was examined by the following goodness-of-fit statistics: Chi-Square value with corresponding p-value, normed Chi-Square (χ/df), Root Mean Squared Error of Approximation (RMSEA), 90%-confidence interval of the RMSEA, Standardized Root Mean Square Residual (SRMR) and Comparative Fit Index (CFI).Chi-Square value with its corresponding p-value belongs to the class of absolute fit indices, measuring how well a specific model fits in comparison to no model at all. The Chi-Square statistics assess the magnitude of discrepancy between the sample and fitted covariance matrices normed Chi-Square which takes the degrees of freedom (χ/df) into account. In the present study, therefore, less weight was given to the Chi-Square test than to the descriptive measure of the normed Chi-Square. The smaller the ratio of the normed Chi-Square the better is the fit of the model. Recommendations for an acceptable ratio range from 5.0 to 2.0 with a good fit below a value of 3.0 The Root Mean Squared Error of Approximation (RMSEA) is an indicator of the discrepancy between the model and data covariance matrices per degree of freedom The Standardized Root Mean Square Residual (SRMR) represents the square root of the difference between the residuals of the sample covariance and the hypothesized covariance model. Values of the SRMR range from 0 to 1 with acceptable models obtaining values up to.08 The Comparative Fit Index (CFI) is a revised version of the Non-Normed Fit Index (NNFI), also known as Tucker-Lewis Index The The goodness-of-fit statistics of the factor model as proposed in EFA of the present study were compared to the cut-offs and recommendations as cited above. Additionally, fit statistics of the multitrait model were compared to the fit statistics of a single common factor model which served as a competing model. Once the overall fit of the model has been evaluated, each model coefficient was individually examined for its degree of fit. This was achieved by t-tests testing the null hypothesis that the true values of specified factor loadings are zero. All items with non-significant factor loadings (p≤.05) were deleted from further analysis Stigmatization was analyzed in descriptive statistics on the sample (n = 1033) on the basis of the extracted factor structure. Subsequently, a dependent sample ANOVA with post-hoc pairwise comparisons was performed to assess differences in stigmatization between subscales. The effects of gender and age on stigma were assessed with t-tests for independent samples and Pearson product-moment correlations, respectively. Statistical tests were calculated separately on extracted stigma subscales which led to α-accumulation. To counteract the problem of multiple comparisons, the significance level α was adjusted by using a Bonferroni correction. Moreover, effect sizes (Cohen’s d) were calculated for all comparisons. Following Cohen’s guidelines for interpreting effect sizes Stigmatization of teachers, physicians and control participants was explored on the basis of the extracted factor structure. A multivariate analyses of variance (MANOVA) with post-hoc pairwise comparisons (Scheffé) was calculated to compare stigmatization between the three groups on each subscale and on the total scale. Moreover, effect sizes (Cohen’s d) were calculated for all comparisons. Following Cohen’s guidelines for interpreting effect sizes Subsample 1. A Kaiser-Meyer-Olkin value of.86 supported sampling adequacy for the analysis and can be categorized as meritorious according to Kaiser 2(2016) = 8258.3, p<.001). PCA using orthogonal rotation (Varimax) initially identified 17 components meeting Kaiser’s criterion of an eigenvalue >1 which explained 61.1% of the total variance. Items were initially retained when they loaded on a factor with a minimum loading of.40 but did not load to any other factor higher than.39. However, on the basis of a scree plot inspection and calculations of the internal consistency , it was justified to extract six of the initial components with a total of 37 items for further exploration. All of the six components had eigenvalues ranging from 2.64 to 5.47. eigenvalues and the percentage of explained variance for each of the six components. The six components of the PCA were interpreted as the following subscales of the questionnaire: Reliability and Social Functioning of adults with ADHD (factor 1), Malingering and Misuse of Medication (factor 2), Ability to Take Responsibility (factor 3), Norm-violating and Externalizing Behavior (factor 4), Consequences of Diagnostic Disclosure (factor 5) and Etiology of adult ADHD (factor 6).Psychometric properties were assessed by applying EFA on The overall scale reliability  of the 37 items was high (Cronbach’s α = .91). The scale reliabilities of the six subscales (Cronbach’s α) ranged between.61 and.87, with.60 indicating the minimum acceptable and 0.80 indicating good reliability. 2 (614) = 1763.68; p<.01). More crucial, the normed Chi-Square value was within a range indicating a good fit (χ2/df = 2.87). Both a RMSEA of.06 and its 90%-confidence interval  also pointed to a well-fitting model. The SRMR of.07 was below the recommended cut-off of.08 and therefore further supported the model fit. Finally, the incremental fit index (CFI = .93) also revealed an acceptable model fit. In summary, the CFA resulted in a satisfactory fit for the present 6-factor model. The proposed 6-factor model outperformed a single common factor model (χ2 (629) = 2680.78 p<.01; χ2/df = 4.3, RMSEA = .099, 90%-CI for RMSEA = ; SRMR = .082; CFI = .87) in all indices. To investigate each model coefficient individually, t-values for factor loadings were inspected. Significant loadings were found for each item (p<.01). Therefore, no items had to be excluded.Regarding the overall fit of the model, the Chi-Square statistics led to rejection of the model (χConsequences of Diagnostic Disclosure) followed by subscale 1 , subscale 4 , subscales 3 (Ability to Take Responsibility) and 6 (Etiology) and finally subscale 2 . Effect sizes of pairwise comparisons ranged from negligible size to large size  = 295.2; p<.001). Post-hoc pairwise comparisons revealed significant differences between all pairs of subscales with the exception of the comparison between subscale 1 and subscale 4 and between subscale 3 and subscale 6 . Particirge size .For the analysis of the effects of gender and age, a Bonferroni adjusted significance level of p = .0083 was applied because of multiple comparisons/correlations . Stigma scores of female respondents  were compared to the scores of male respondents  using t-tests for independent samples . Male reStigma responses of teachers, physicians and control participants are presented in Empirical research directly addressing stigma in ADHD is sparse. One difficulty in studying this topic is the lack of appropriate measures. Therefore, a new questionnaire on stigma in adults with ADHD has been developed in the present study. The aims of this development were (I) to identify dimensions that specifically meet stigmatizing issues persons with ADHD are confronted with, (II) to transfer the knowledge gained from research on childhood ADHD to the adult population, and finally (III) to examine the sensitivity of the questionnaire in measuring differences of stigmatizing attitudes between groups by comparing stigma responses of teachers, physicians and matched control participants.The questionnaire consists of 37 items directly addressing stigmatizing beliefs on adults with ADHD. Exploratory factor analysis (EFA) revealed a 6-factor structure which was empirically confirmed by a confirmatory factor analysis (CFA). The devised 6-factor structure has been supported in overall fit indices and by inspecting each model coefficient individually. Furthermore, the 6-factor structure has been shown to be superior to a single common factor model.Consequences of Diagnostic Disclosure.Research demonstrated that the mere label of a psychiatric condition can trigger stigmatization Reliability and Social Functioning. This factor may reflect the difficulties of individuals with ADHD in maintaining social relations, friendships and partnerships Participants’ responses to statements that adults with ADHD are not reliable, less trustworthy, self-focused, egoistic and careless about other’s problems have been found to load on a common factor which has been labeled Ability to Take Responsibility encompasses statements, which refer to situations in which individuals with ADHD take over the responsibility for another individual, a family or a business . Getting stigmatized on this factor implies doubts about the social, academic and vocational abilities of the person with ADHD. Adverse academic outcomes and adverse career developments might be possible consequences. In fact, it has been shown that persons with ADHD often encounter a range of problems in the occupational setting, comprising peer relational problems accompanied with adverse academic and vocational outcomes The factor Malingering and Misuse of Medication. Stigmatizing believes point to severe doubts about the existence of ADHD in public which can lead to detrimental consequences for affected individuals. For example, the necessity for treatment can be questioned, the access to treatment can be hindered, and help seeking behavior may become discouraged in the individual with ADHD. Furthermore, effective psychosocial and pharmacological intervention strategies may be refused. In conclusion, adverse adherence to and low efficacy of treatment might result.Another important issue in explaining the emergence of stigmatization in ADHD lies in the doubts concerning the existence of ADHD as a disorder Norm-violating and Externalizing Behavior refers to society’s understanding of ADHD which is dominated by the occurrence of behavioral disturbances associated with the condition, in particular with the preeminent hyperactive-impulsive symptoms which are a defining characteristic of childhood ADHD The factor labeled Etiology and implies common stigmatizing beliefs about the etiology of ADHD (e.g. in claiming that adults with ADHD do not engage enough in sports or that extensive exposure to video games and TV shows cause ADHD). The importance of this dimension is indicated by findings showing that knowledge about the etiology of mental disorders, such as ADHD, may adjust stigmatizing beliefs Finally, a dimension has been identified concerning the causes of the condition. This factor has been labeled The present study did not reveal a factor focusing on medication use. This might appear surprising, since misperception and stigmatizing beliefs about long-term effects of medication in ADHD were repeatedly reported Malingering and Misuse of Medication). Significant more stigmatization with small effects were found on subscale 3 (Ability to Take Responsibility) and subscale 6 (Etiology). Representative items for these factors are item 3 for subscale 2 (“Many adults with ADHD simulate the symptoms”), item 2 for subscale 3 (“I would mind if my investment advisor had ADHD”) and item 23 for subscale 6 (“Adults with ADHD do not engage enough in sports”). Stigma responses on these subscales were exceeded by stigma scores on subscale 1 , subscale 4  and subscale 5 (Consequences of Diagnostic Disclosure). These differences were of small to large size. Within these subscales, high stigmatizing responses were observed on item 15 (“Adults with ADHD care less about other’s problems”) and item 6 (“People’s attitudes about ADHD make persons with ADHD feel worse about themselves”). These results shed light on the trouble persons with ADHD are assumed to have in social life, for example with making friends, being trustworthy, being empathic and caring about other peoples’ problems. These findings refer also to the public’s assumption of socially inappropriate behavior of persons with ADHD which might result in a lower social status. Moreover, the mere diagnostic label and its disclosure is believed to have adverse effects on affected individuals’ self-esteem and general well-being as reflected in high stigmatizing responses. In this context, educational programs aiming to inform the general public about ADHD might be of particular value in reducing the stigmatizing label bias. Previous research already demonstrated that an increase of knowledge about ADHD  is in general an effective approach in reducing stigmatizing beliefs The overall level of stigma was found to be low to moderate as reflected in negative values for all subscales. Even though the absolute value is difficult to interpret due to lacking reference values, conclusions can be drawn on the basis of comparisons of stigmatizing responses between subscales. Except of two comparisons , stigma responses on all subscales differ significantly from each other. Effect sizes between subscales ranged from negligible to large effects, supporting the notion that different dimensions of stigmatization towards adults with ADHD were measured. The lowest stigma responses could be shown on subscale 2 . This is supported by the finding that an increasing number of students present themselves to specialists at the post-secondary-level because of ADHD symptoms In line with previous research Reliability and Social Functioning, Malingering and Misuse of Medication and Norm-violating and Externalizing Behavior. Physicians showed significantly less stigmatization on the subscales Malingering and Misuse of Medication as well as Etiology. Although teachers and physicians did not differ from control participants on the total scale, the present results indicated that teachers and physicians are more sensitive to stigma in ADHD, at least in some aspects. Moreover, different patterns of differences between teachers and physicians in comparison to control participants were found, as indicated by lower stigma of teachers but not physicians on the subscales Reliability and Social Functioning and Norm-violating and Externalizing Behavior. However, lower stigma responses were found concerning the etiology of ADHD in physicians but not teachers. Considering the educational background of teachers and the expert knowledge of physicians, it is not surprising that physicians were more sensitive with respect to the etiology of ADHD than the general population, while teachers were more sensitive to the functioning of individuals with ADHD. Teachers of course experienced that children with ADHD can learn to cope with their problems and difficulties under certain circumstances, that they have social skills and that they can take over responsibilities. Teaching and mentoring these children over a longer period of time, sometimes even till early adulthood, might provide them with a unique insight in the development of individuals with ADHD. Consequently, teachers might see much more the potential in individuals with ADHD than the general population, making them less prone to stigmatize individuals with ADHD. The different profiles observed therefore most likely reflect the effect of different trainings and experiences between more experienced groups (teachers and physicians) and the general population (control participants). These different profiles, however, also point to the existence of different qualities/dimension of stigmatization. Finally, the detection of these differences also indicates that the questionnaire presented appears to be sensitive with regard to stigmatization of adults with ADHD.When studying stigmatization towards a developmental disorder such as ADHD, people working in the educational or health care sector are of particular interest. Teachers, on the one hand, received a specialized training in educational sciences and have contact to a wide range of youngsters and accompany them in their development from childhood through adolescence into adulthood. Therefore, teachers can be assumed to be more sensitive towards developmental disorders such as ADHD and to be less prone to stigmatizing attitudes towards those affected by these disorders. Physicians, on the other hand, successfully completed a university study program in medicine and have a broad understanding of factors underlying human behavior. Moreover, stigma is a concept that is quite salient in medicine, since individuals with many different physiological, psychosomatic or psychological conditions experience stigmatization. Consequently, physicians have a higher chance to get in contact with people experiencing stigmatization than the general population. Furthermore, many physicians might even be informed by their professional associations, colleagues, conferences or any other additional training about the existence of ADHD in adulthood and the problems involved. Therefore, physicians are presumably also more sensitive with regard to stigmatizing beliefs and attitudes. However, analysis of the present data revealed that teachers, physicians and control participants did not differ on the overall level of stigmatization. Nevertheless, teachers and physicians could be found to show lower scores than control participants on certain aspects of stigma. Significantly lower stigma responses were found for teachers in statements focusing on Reliability and Social Functioning, Malingering and Misuse of Medication, Ability to Take Responsibility, Norm-violating and Externalizing Behavior, Consequences of Diagnostic Disclosure and the Etiology of adult ADHD appear to be crucial dimensions when dealing with the construct of stigma in ADHD. The application of the questionnaire may support in the process of the development of effective prevention and intervention strategies against stigmatization of adults with ADHD and persons with related psychiatric conditions.In the present study, a new questionnaire with six subscales assessing stigmatization in adults with ADHD has been described. The psychometric properties of these subscales were carefully evaluated and the factor structure was replicated as suggested by Hinkin


Currently, β-blockers are used most frequently for the purpose of heart rate (HR) control in patients with atrial fibrillation (AF) in worldwide. Carvedilol is one of common β-blockers and known to be effective for hypertension and heart failure. However, little can be found the information about the HR-lowering effect of carvedilol in patients with AF without heart failure. Therefore, we conducted this study to investigate the effect of carvedilol on HR in 3-minute electrocardiogram (ECG) and total heart beats (THBs) in 24-hour Holter ECG monitoring in patients with persistent or permanent AF.A total of 13 hypertensive patients  with AF and HR 90 bpm or more were enrolled. All patients received carvedilol from 5 mg/day. The dose of drug was titrated every 4 weeks and raised to 10 or 20 mg/day if HR was 80 bpm or more.Mean HR was decreased from 101.9 ± 13.9 to 85.2 ± 15.2 bpm (P < 0.05) after treatment with carvedilol. THBs were also significantly decreased from 128 to 115 × 1,000/day (P < 0.001). Percent reduction in HR and THBs were 13.9% and 10.7%, respectively. The scores of Atrial Fibrillation Quality of Life Questionnaire (AFQLQ) did not change. Only one patient was required to discontinue carvedilol due to congestive heart failure.We observed that carvedilol certainly reduced HR in patients with chronic AF. We believe that the effect of carvedilol on the reduction in HR can contribute to the management of AF patients treated with rate-control strategy. Atrial fibrillation (AF) is a most common sustained arrhythmia in daily clinical practice. Since AF is a potent risk factor for disability and impairing quality of life (QOL) associated with cardiogenic ischemic stroke and congestive heart failure, AF is important disease to be managed. Current strategies for the management of AF include the medical treatment with antiarrhythmic drugs to maintain sinus rhythm or the use of rate-controlling drugs allowing AF to persist. In both approaches, the anticoagulation therapy should be recommended. According to the results from several large clinical trials after 2000 , the outA total of 13 patients with AF were enrolled in this study. All patients had been diagnosed hypertension and persistent or permanent AF prior to starting the carvedilol treatment. All patients exhibited heart rate of 90 beats/minute (bpm) or more evaluated by numbers of QRS complex during any one minute in 3-minute ECG; even though the patients had received any heart rate-lowering agents except β-blockers. Carvedilol was given to the patients who had no changes in their current medications for at least three months prior to starting carvedilol. Hypertension was diagnosed when office blood pressure was ≥ 140/90 mmHg , if the All patients were given carvedilol starting from a dose of 5 mg/day. After observation for 4 - 8 weeks, the dose of carvedilol was raised to 10 mg/day if patient’s resting heart rate was 80 bpm or more , 12 and 0.5) [The primary endpoints of this study were 1) heart rate evaluated by numbers of QRS complex during any one minute in 3-minute ECG, 2) total heart beats in 24-hour Holter ECG monitoring before and after treatment with carvedilol. Secondary endpoints were patient QOL scores  and adve0.5) , and widData are presented as the mean ± standard deviation (SD). Statistical differences of the parameters between at the baseline and at each observation period were analyzed by a one-way repeated-measures analysis of variance (ANOVA) followed by Student’s t-tests for paired data with the Bonferroni correction. Differences of the parameters between before and after treatment with carvedilol were analyzed by a paired Student’s t-test. Comparison among unrelated 2 or 3 groups were analyzed by Student’s t-test or one-way ANOVA. Differences with P-values of less than 0.05 were considered to be statistically significant. All statistical analyses were performed using the SigmaStat version 3.5 software program .The baseline characteristics of patients in the present study are shown in 2The changes in heart rate at each observation period are shown in The results of Holter ECG monitoring were shown in The scores of AFQLQ including either 3 subset  did not improve after treatment with carvedilol in patients with chronic AF .Adverse effects were observed in 3 cases. Of these, only one male patient was required to discontinue carvedilol 8 weeks after treatment with 5 mg/day due to the occurrence of congestive heart failure. Although his left ventricular function was preserved at 58% in ejection fraction, he was the sole patient suffered from old myocardial infarction and the oldest (86 years) in this study. One patient felt tinnitus during receiving carvedilol but he was able to complete the protocol with the dose of 20 mg/day. In another female patient, skin eruption appeared during observation period which was diagnosed asteatotic eczema, not an allergy for carvedilol. She could finish the protocol on her final dose of 10 mg/day. All adverse effects were not severe and the latter two incidents were probably not associated with carvedilol. One patient could not complete follow-up period except adverse effect because AF returned to sinus rhythm after finishing evaluation of parameters on the dose of 5 mg/day.Changes in the other parameters measured in the present study were summarized in The major finding of the present study was that carvedilol significantly reduced heart rate in 3-minute ECG and total heart beats in 24-hour Holter ECG monitoring. Although this study was conducted in a small number of subjects, promising results for primary endpoints were observed.1-adrenoreceptor blocking action [Carvedilol, a nonselective β-blocker, has not only β-adrenoreceptor blocking effect but also vasodilating effect resulting in the reduction in total peripheral vascular resistance. The latter is mainly thought to be caused by αg action . In addig action  and a pog action  but alsog action , 23.Even in stable outpatients with chronic AF, uncontrolled rapid heart rate can result in the development of congestive heart failure and/or impairment of QOL. Therefore, heart rate control is important and necessary to prevent heart failure and any impairment, though mortality in patients treated with rate-control strategy was comparable with those in rhythm-control strategy .Present study demonstrated that carvedilol could certainly reduce heart rate in patients with chronic AF. However, %change in heart rate was not consistent in all patients. In fact, %reduction in heart rate in the groups of lower doses of carvedilol was larger than that in the group of 20 mg, despite it did not reach significant difference. The reason for these results could be explained by that patients were not randomized to divide into 3 groups in this study and the final daily dose of carvedilol was chosen by titration according to heart rate before raising a dose and tolerance for this drug. Similarly, %reduction in heart rate in patients with other heart rate-lowering drugs was significant smaller than that without use of these drugs. These results indicated that the patients consequently needed higher doses of carvedilol and/or those with the use of other heart rate-lowering drugs were resistant to the heart rate-lowering therapy. The sympathetic nerve activity in these patients would have been higher.Since the casual heart rate can easily be modified by unstable situation, in particular the status of sympathetic nerve activity as well as white coat phenomenon on office blood pressure, total heart beats in 24-hour Holter ECG monitoring were evaluated to confirm the heart rate-lowering effect of carvedilol. Present study demonstrated that carvedilol could certainly reduce total heart beats in 24-hour Holter ECG monitoring in patients with chronic AF. An interesting finding was that carvedilol did not affect minimum heart rate despite maximum and mean heart rates significantly decreased; suggesting that carvedilol would not cause excessive response resulting in bradycardia. It would be beneficial for the management of AF patients to avoid any complication caused by bradycardia such as pacemaker implantation. Another important finding that total heart beats and mean heart rate in 24-hour Holter ECG were definitely decreased by the treatment with carvedilol in all subjects; even in some patients with increasing response to casual heart rate in the situation of outpatient clinic; indicating that the effect of heart rate-controlling drugs should be evaluated by not only casual heart rate but also total heart beats or mean heart rate using 24-hour Holter ECG monitoring.No improvement of AFQLQ scores could be found after treatment with carvedilol in the present study. In J-RHYTHM study , the AFQIt was required to discontinue carvedilol in only one case with old myocardial infarction. This fact taught us again that β-blockers should be prescribed with caution to elderly patients even though who have no history of heart failure and ejection fraction is within normal range.This study had several limitations. First, this study was performed in a single institution and had a small sample size. It was actually difficult to recruit patients for this study, because most AF patients had already received any β-blocker and their heart rates were well-controlled less than 90 bpm which was enroll criteria. However, even in a small number of subjects, the heart rate-lowering effect of carvedilol was obvious and statistically significant. Second, the dose of carvedilol was not randomized. Since the final daily doses of carvedilol were determined by titration, it could be explained the reason why %reduction in heart rate in patients receiving maximum dose of carvedilol was less than that in those receiving lower doses. However, the present method of titration to raise a dose of β-blocker would be more safety and recommended in real-world clinical situation.In conclusion, we observed that administration of carvedilol reduced heart rate in patients with chronic AF without congestive heart failure. We believe that the effect of carvedilol on the reduction in heart rate can contribute to the management of AF patients treated with rate-control strategy and the prevention from complications in future.


Much of what we know regarding the effect of stimulus repetition on neuroelectric adaptation comes from studies using artificially produced pure tones or harmonic complex sounds. Little is known about the neural processes associated with the representation of everyday sounds and how these may be affected by aging. In this study, we used real life, meaningful sounds presented at various azimuth positions and found that auditory evoked responses peaking at about 100 and 180 ms after sound onset decreased in amplitude with stimulus repetition. This neural adaptation was greater in young than in older adults and was more pronounced when the same sound was repeated at the same location. Moreover, the P2 waves showed differential patterns of domain-specific adaptation when location and identity was repeated among young adults. Background noise decreased ERP amplitudes and modulated the magnitude of repetition effects on both the N1 and P2 amplitude, and the effects were comparable in young and older adults. These findings reveal an age-related difference in the neural processes associated with adaptation to meaningful sounds, which may relate to older adults’ difficulty in ignoring task-irrelevant stimuli. Auditory adaptation refers to the reduction of neural responses when a sound is heard repetitively within a period of several seconds ,2. It isEvidence from ERP studies suggest that aging may be associated with deficits in inhibitory control e.g., ,13,14) a,14 a13,1To date, studies that focused on ERP adaptation have generally used pure tones e.g., ,23,24). ,24. 23,2The present study was approved by the Research Ethics Board of the Toronto Academic Health Sciences Network and the University of Toronto and Baycrest Centre Human Subject Review Committees. Participants gave written informed consent before participating in the study and were paid for their participation in the experiment.Twelve young adults (mean age ± standard deviation (SD), = 25.2 ± 3.9; 5 men) and twelve older adults  volunteered to participate in this study. Participants were recruited from the local community and laboratory personnel at the Rotman Research Institute, Baycrest Centre. They were screened to exclude health problems and/or medications that might affect cognitive function and brain activity. All participants had pure-tone thresholds less than or equal to 20 dB hearing level (HL) in the range of 250-2000 Hz in both ears. Older adults scored in the normal range, between 27 and 30  = 0.79), on the Mini-Mental State Examination which is a brief 30-point questionnaire test commonly used to screen for cognitive impairment )Prior studies using pure tones have identified several N1 subcomponents based on the waveform latency and scalp distribution ,56,57. AIn the present study, domain specific neural adaptation was examined by analyzing the interaction between trial type and position and the magnitude of amplitude change evoked by the first compared to the last sound in the train among the four trial types. For the N1 wave, we found a general decrease in amplitude, which was little affected by the trial type. That is, N1 adaptation was comparable no matter whether the same or different sound was presented at the same or different location. Therefore, in the present study, the N1 wave appears to reflect the general encoding of acoustic energy elicited by sound onset irrespective of the early spectro-temporal details and/or location of the stimulus. The lack of domain-specificity in N1 suppression is consistent with the notion that the N1 wave reflects the registration of sound stimuli and/or signal detection as opposed to signal discrimination . AnotherThe first sign of domain specificity was observed during the P2 wave in young adults. Specifically, we found greater P2 amplitude suppression when sound location was repeated (while sound identity changed) than when sound identity was repeated (while sound location changed). This kind of domain-specific adaptation could be explained by the sharpening model described by Grill-Spector et al. ,63. In tIn addition to the sharpening and the fatigue models, Grill-Spector et al.  also proIn the present study, the P2 wave showed differential patterns of neural adaptation to sound identity and location repetition among young adults. This is in line with visual ERP studies showing that stimulus repetition produced an ERP difference around 150 ms that was greater for repeated visual objects with the same view than with a different view, whereas adaptation for the same object presented at a different field of view was observed subsequently between 400 and 700 ms post-stimulus ,66.SSL) than those with varied location but identical sounds  in the present study. Also, as seen in the results, the primary difference between the DSSL and SSDL trials is the number of stimuli in the stimulus train required to reach maximum suppression. When the location is fixed and the sound identity is changed, only one stimulus repetition is needed to yield maximum P2 suppression, but when the location is changed, two more stimulus repetitions are needed . This faster adaptive response to sound location is in line with the results of Diaconescu et al. [In the present study, young adults showed greater adaptation to location than identity repetition. This is demonstrated by a greater P2 amplitude decline in location repetition compared to identity repetition. One explanation is that location activates neural responses early in the processing of complex sounds , which cu et al.  who founu et al. . Moreoveu et al. .Our results showed no domain-specific adaptation in older adults. This result is consistent with Grady et al.’s  study, wThis study explicitly tested the effect of noise on neural adaptation to everyday sounds. Using ERPs, we found that older adults showed reduced adaptation with or without background scanner noise. This finding indicated that the age-related difference in neural adaptation observed in Grady et al.’s study was not simply due to the noisy MRI environment. The current study compared patterns of neural adaptation between young and older adults and revealed age-related differences in neural adaptation to real life, meaningful sounds, which replicate and extend prior research that used sinusoidal pure tones or harmonic complex sounds. The findings from the present study show that aging not only impairs the encoding of sound features but also appears to impede the formation of sound object representation in sensory memory.In this study, we used real life, meaningful sounds and simulated scanner noise, and found neural adaptation in both N1 and P2 waves among young adults but only on N1 waves among older adults. While young adults were able to adapt to identity or location repetition, i.e., domain-specific adaptation, in both the presence and absence of simulated scanner noise, older adults did not seem to adapt as efficiently as young adults. The patterns of neural adaptation were different between young and older adults, with older adults showing smaller amplitude changes than young adults across trains of identical sound stimuli. We also found that only young adults showed domain-specific adaptation on P2 amplitudes. These findings indicate that the neural processes associated with adaptation of meaningful sounds differ between young and older adults.


Web-based computer-tailored approaches have the potential to be successful in supporting smoking cessation. However, the potential effects of such approaches for relapse prevention and the value of incorporating action planning strategies to effectively prevent smoking relapse have not been fully explored. The Stay Quit for You (SQ4U) study compared two Web-based computer-tailored smoking relapse prevention programs with different types of planning strategies versus a control group.To assess the efficacy of two Web-based computer-tailored programs in preventing smoking relapse compared with a control group. The action planning (AP) program provided tailored feedback at baseline and invited respondents to do 6 preparatory and coping planning assignments . The action planning plus (AP+) program was an extended version of the AP program that also provided tailored feedback at 11 time points after the quit attempt. Respondents in the control group only filled out questionnaires. The study also assessed possible dose–response relationships between abstinence and adherence to the programs.The study was a randomized controlled trial with three conditions: the control group, the AP program, and the AP+ program. Respondents were daily smokers (N = 2031), aged 18 to 65 years, who were motivated and willing to quit smoking within 1 month. The primary outcome was self-reported continued abstinence 12 months after baseline. Logistic regression analyses were conducted using three samples: (1) all respondents as randomly assigned, (2) a modified sample that excluded respondents who did not make a quit attempt in conformance with the program protocol, and (3) a minimum dose sample that also excluded respondents who did not adhere to at least one of the intervention elements. Observed case analyses and conservative analyses were conducted.P = .005) and the AP+ program  were significantly more effective than the control condition. Abstinence rates and effects differed per sample. Finally, the results suggest a dose–response relationship between abstinence and the number of program elements completed by the respondents.In the observed case analysis of the randomized sample, abstinence rates were 22% (45/202) in the control group versus 33% (63/190) in the AP program and 31% (53/174) in the AP+ program. The AP program  Smoking relapse rates can be extremely high (up to 90% in the first 3 months), and only 3%-5% of quitters maintain their quit attempt for 6 months or longer . The rolAdding action planning components to programs may be a promising strategy for improving smoking relapse prevention programs -12. PlanThe Internet has proven to be a promising delivery mode for health-promoting and lifestyle-changing interventions . In sum, the main goal of the Stay Quit for You (SQ4U) study was to assess the efficacy of two relapse prevention programs: (1) an action planning (AP) program that provided tailored feedback based on the baseline questionnaire and 6 preparatory and coping planning assignments, and (2) an action planning plus (AP+) program that extended the AP program by providing tailored feedback at 11 time points after the quit date. The efficacy of the programs was compared with that of a control group (with no intervention). Moreover, we aimed to assess possible dose–response relationships between abstinence and adherence to the number of program elements. First, we expected both programs to be more effective than the control condition in fostering continued abstinence 12 months after the start of the study (hypothesis 1). We expected the AP+ program to be the most effective. Moreover, we expected to find a dose–response relationship between continued abstinence and intervention dose (hypothesis 2). Finally, we will provide an overview of the respondents’ program evaluations.Ethics approval was obtained from the Medical Ethics Committee of Maastricht Academic Hospital and Maastricht University . The study is registered with the Dutch Trial Register (NTR1892).We recruited smokers by placing ads in local newspapers, distributing 10,000 flyers in the city of Maastricht, and placing online ads on the websites of national health funds, a national news page, and the Dutch Foundation for a Smoke-free Future. The ads referred the respondents to our research website for more information. All data were gathered via the Web and there was no face-to-face contact between respondents and the study team. A software program randomly assigned a total of 2681 respondents to one of the three conditions using a simple randomization type (see design below). The enrollment and inclusion of respondents is presented in The SQ4U study was a randomized controlled study with a control condition and two experimental conditions. Respondents registered via the research website and made their own login account (each time they were invited for participation they received this account in the invitation mail). After registration, respondents were randomly assigned to one of the three programs outlined in the Introduction. Respondents in the intervention groups were invited by email or text message  to perform intervention tasks . The same procedure was used to invite all respondents for the 12-month follow-up measurement. Reminder emails were sent when respondents did not respond to the follow-up measurement, which asked them to report on their smoking behavior using self-assessed questionnaires. Respondents who reported that they were abstinent were asked to take biochemical validation tests (see below). Respondents who completed all parts of their assigned SQ4U variant (including those in the control group) were eligible to win 1 of 20 prizes of €250. A more detailed description of the development, design, study course, biochemical validation, and intervention elements can be found elsewhere .We used cotinine assessments to validate reports of abstinence in a subsample (n = 70) of the respondents. This verified the nonsmoking status self-reported by respondents at the 12-month follow-up measurement. Only 1 (1%) respondent showed positive cotinine results and admitted to having smoked. Another respondent admitted to smoking when invited for biochemical validation. The smoking status for these 2 (3%) respondents was changed to relapse.Feedback focused on respondents’ perceptions of smoking and quitting and was based on previously tested effective computer tailoring programs that used the I-Change Model ,20. The Since planning assignments have proven to be promising strategies to foster cessation and prevent relapse, the SQ4U programs incorporated assignments designed to motivate respondents to use these strategies to make a quit attempt  and to prevent relapse . Two assignments focused on making and carrying out preparatory plans; 2 more assignments addressed coping planning. Finally, 1 assignment focused on a specific coping plan (making an emergency plan for coping in case of a lapse) and 1 assignment required making a specific preparatory plan (planning a reward for abstaining from smoking for some time).Studies that use ecological momentary assessments to gain in-depth, day-to-day information on the process of quitting have noted that low self-efficacy and negative affect preceded lapsing -40. TherThe following basic information was collected about each respondent:Demographic variables assessed age, gender, and educational level .Perceived stress was assessed by 5 items based on the Perceived Stress Scale [ss Scale  and was Level of depression was measured by 10 items  using the Center for Epidemiologic Studies Depression scale [on scale . The ansLevel of dependence was assessed by 5 items  based on an abbreviated Fagerström test [röm test ,44. The The following questions about intention and motivational factors were based on questions used in previous studies ,20,45-47Attitudes were measured on a 4-point scale  with four subscales measuring the following: (1) pros of not smoking, expressed by 9 statements representing positive expected outcomes  , (2) cons of not smoking, expressed by 9 statements representing negative expected outcomes  , (3) pros of relapse, expressed by 4 statements representing positive expected outcomes  , and (4) cons of relapse, expressed by 6 statements representing negative expected outcomes  .o Social support was measured by 5 items that asked about the support received from significant others  on a 4-point scale . A “not applicable” response was coded as missing. We created an index and used these scores in the analyses.o Modeling was assessed by 5 items that measured the smoking status of the partner  and residential children, parents, colleagues, and friends . The items were coded into three category scales . The items were summed and formed an index that we used in the analyses; smoking status of the partner was included separately in the analyses.o Self-efficacy was assessed by 13 items that asked whether respondents thought they would be able to refrain from smoking in various smoking-related high-risk situations such as parties . Recovery self-efficacy was assessed by 7 items that asked whether respondents thought they would be able to resume a smoking cessation program after a lapse  . Answers were given on a 5-point scale  and the mean score was used in the analyses.o Preparatory planning was assessed by 12 items Continued abstinence at 12 months after baseline was the primary outcome. In line with the definitions provided by Hughes et al , we defiThe most common approach to analyzing the effects of interventions is to include all respondents randomly assigned to the programs. The advantage to this approach is that it reflects the situation as it is likely to occur in practice . This strategy also maintains the balance between randomly assigned groups and preserves sample sizes ,50. On tsample as randomized, including all respondents. Since this study focused on relapse prevention and therefore on continued abstinence, we also report on smaller samples:Sample 1 is the the modified sample, excluded respondents who indicated after their quit date as well as at follow-up that they did not make a quit attempt, and those who reported that they had quit less than 320 days before the follow-up measurement (this is after about 2 weeks after the first month in which they were supposed to make an attempt). We excluded the latter group because one of the inclusion criteria was that respondents needed to set a quit date within 1 month after inclusion. Including respondents who explicitly stated that they made their quit attempt much later or even too close to the follow-up measurement would result in differences between respondents in the time frame from the quit attempt to the follow-up measurement.Sample 2, referred to as minimum dose sample, excluded respondents who did not adhere to at least one element of the program they were assigned to  in addition to meeting the exclusion criteria in the modified sample.Sample 3, referred to as the For all three samples, we conducted an observed case analysis (only including respondents with follow-up data) and a conservative analysis in which we assumed that participants missing at follow-up had relapsed to smoking. We used a logistic regression analysis to compare the efficacy of the control condition and the SQ4U programs to foster continued smoking abstinence after 12 months. Differences in baseline factors  were assessed using chi-square tests for categorical variables and analysis of variance for continuous variables. Attrition was analyzed by logistic regression and included baseline factors. To preserve power, we included only baseline factors on which the three conditions significantly differed at baseline as well as the factors that significantly predicted dropout at follow-up as covariates in the effect analyses. Listwise deletion with regard to missing values was used. Finally, chi-square tests were used to assess the existence of dose-response relationships within the SQ4U programs using the observed cases in sample 2 (the modified sample) to conform to the methods used by Borland et al .P > .05) differences between the three conditions on the baseline measurements of perceived stress, depression, intention strength, social influence, attitude, self-efficacy and recovery self-efficacy, and preparatory planning. (P = .06) and AP+  programs and respondents who were younger , were male , had a lower education level , perceived fewer advantages to relapse , and had low levels of self-efficacy . In the control condition, 434 of 636 (68.2%) were lost to follow-up versus 508 of 698 (72.8%) in the AP program and 523 of 697 (75.0%) in the AP+ program . AttritiP = .005), sample 2 , and sample 3  when including observed cases only. The AP+ program was, however, only significant in sample 1 . In the conservative analyses, both programs were significantly more effective than the control condition only in sample 3 . Finally, having high levels of self-efficacy was the only consistent predictor of continued abstinence in all these analyses.21 = 7.4, P < .007; AP+: χ21 = 14.7, P < .001) and feedback moments  and confirmed higher abstinence rates when more planning assignments or questionnaires after the quit attempt were completed. On average, respondents in the program groups adhered to 4 out of 6 planning assignments and 6 out of 11 feedback questionnaires.The main goal of this study was to evaluate the efficacy of two Web-based smoking relapse prevention programs (AP and AP+) in the SQ4U study with regard to 12-month continued smoking abstinence. Furthermore, we aimed to assess dose-response associations. Despite the potential of the Internet, a recurrent problem in Internet trials is low adherence to the programs . These lThe results of all three observed case analyses  revealed significant effects in favor of the AP program. We can conclude that most of the analyses support our first hypothesis that planning strategies can be effective in preventing relapse among smokers who are motivated to quit smoking. The AP+ program, on the other hand, only proved to be significantly more effective than the control condition in the randomized sample (sample 1). The approach for sample 2 seems to have created a bias against the AP+ program by excluding respondents who did not make a quit attempt during the study, which resulted in more exclusions of relapsers (since nonquitters cannot be considered to be continued abstinent at follow-up) in the control condition than in the AP+ program (which consisted of elements designed to foster making a quit attempt). This approach may therefore have been too conservative. Furthermore, additional power analyses showed that 2623 respondents would have been needed to find significant differences in abstinence rate between the control group  and the AP+ program group . Therefore, the lack of significance in sample 2 may be due to power issues. Another possible explanation for lack of significant effect for the AP+ program in sample 2 and sample 3 may be that the program was too intensive and therefore resulted in an overload for the respondents that negatively influenced its efficacy. A comparable result was found in an earlier study conducted among vocational students, which tested the efficacy of a standard in-school program, a computer-tailored program, and a combined program . This stWhen conducting conservative analyses, we found the AP and AP+ programs to be significantly more effective than the control condition in the minimum dose sample (sample 3). However, given the large dropout rate, this conservative approach (coding missing participants as relapsers) may be too conservative. Additional descriptive analyses indicated that about 60% of the respondents who dropped out at follow-up were nonsmokers at their last visit, indicating that interpreting all missing cases as treatment failures may be too conservative, a finding also supported by others [The abstinence rate of 22% in the control group is another notable finding, since self-quitters generally reach abstinence rates of only 3%-5% . A possiFinally, the dose-response relationship between abstinence and the number of program elements suggests that a dose-response association may exist. This is because abstinence rates increased by up to 53% 33/62) in the AP program and 51% (36/70) in the AP+ program when doing 5 to 6 planning assignments, and up to 61% (20/33) in the AP+ program when filling out 10-11 feedback questionnaires (on which feedback was provided). These findings suggest, in line with hypothesis 2, that the efficacy of the programs depends on adherence to the program, also found in previous studies ,61. Our  in the AThe SQ4U study was subject to limitations. The first limitation is that the planning assignments and feedback moments were provided at fixed times, while the varying levels of adherence found in our study suggest that programs should perhaps provide support when the respondent needs it most . Research is needed to explore the potential additional efficacy of such an approach. Second, the cut-off point for the minimum dose sample (sample 3) is not based on empirical findings and needs to be explored in additional studies. Third, because of medical ethics guidelines, we could not prevent respondents from using additional help to quit smoking. The use of additional help, however, may interfere with the effects of the programs and may be beneficial or counterproductive. Further research is needed to explore which additional aids may have positive or negative effects. Fourth, our study had a high rate of loss to follow-up , an issue that is very common in comparable studies ,21,63,64Aside from these limitations, our SQ4U study is the first to test the efficacy of incorporating planning assignments in a Web-based computer-tailored relapse prevention program and of combining planning assignments with multiple tailored feedback moments after the quit date. The study reflected on the findings from different samples, and the results pointed out the importance of using planning strategies and tailored feedback moments after the quit date for smokers who are motivated to quit. Previous studies indicated that a lack of preparatory planning is associated with smoking relapse ,9. Our c


Oxygen consumption reflects multiple processes in pancreatic islets including mechanisms contributing to insulin secretion, oxidative stress and viability, providing an important readout in studies of islet function, islet viability and drug testing. Due to the scarcity, heterogeneity, and intrinsic kinetic properties of individual islets, it would be of great benefit to detect oxygen consumption by single islets. We present a novel method we have developed to image oxygen in single islets.Using a microfluidics system, individual islets and a fluorescent oxygen-sensitive dye were encased within a thin alginate polymer layer. Insulin secretion by the encapsulated islets was normal. Fluorescent signal from the encased dye, detected using a standard inverted fluorescence microscope and digital camera, was stable and proportional to the amount of oxygen in the media. When integrated into a perifusion system, the sensing system detected changes in response to metabolic substrates, mitochondrial poisons, and induced-oscillations. Glucose responses averaged 30.1±7.1% of the response to a metabolic inhibitor (cyanide), increases were observed in all cases (n = 6), and the system was able to resolve changes in oxygen consumption that had a period greater than 0.5 minutes. The sensing system operated similarly from 2–48 hours following encapsulation, and viability and function of the islets were not significantly affected by the encapsulation process.An oxygen-dependent dye situated around and within a pancreatic islet encapsulated by a thin layer of alginate was sensitive to changes in oxygen consumption, and was not harmful to the function or viability of islets over the course of two days. The microcapsule-based sensing method is particularly suited to assessing the effects of compounds (dose responses and time courses) and chronic changes occurring over the course of days. The approach should be applicable to other cell types and dyes sensitive to other biologically important molecules. Oxygen consumption rate (OCR) is a critical parameter to assess as part of investigations of islet physiology and viability. Oxygen is the final acceptor of electrons traversing the electron transport chain (ETC), and in islets oxygen utilization associated with the ETC represents most of the total cellular OCR Due to the importance of OCR for studies of cells of all types, there have been a number of approaches to its measurement. In general, these are broken down into two categories, flow and static systems. Use of flow systems involves measuring the difference between inflow and outflow oxygen content, whereas in the static systems the decrease in oxygen content in a closed chamber is measured over a period of time. Flow systems are able to resolve temporal changes in islet respiration in response to the presence or washout of effector agents. Two static systems that have been used for islet studies include mixed chambers that are equipped with a Clark oxygen electrode In general, to be able to measure the decrement in oxygen tension in bulk solution (flow or well-mixed) a relatively large number of islets must be used. A mode of real time analysis of OCR by single islets utilizes oxygen-specific sensors to measure oxygen tension in media surrounding or inside the islet Encapsulation has been tested as a way to provide an immunoprotective barrier when transplanting islets into diabetic patients Recently, microfluidic techniques have advanced cell encapsulation by using hydrogels or other biopolymers as the microcapsules 2, varying amounts of glucose , and 20 mM HEPES . The agents used in perifusion experiments were potassium cyanide (KCN), carbonyl cyanide 4-(trifluoromethoxy)phenylhydrazone (FCCP), and nimodipine (Sigma-Aldrich). Additional agents used in the encapsulation procedure were soybean oil , Sterile sodium alginate (endotoxins<100 EU/g) , and the detergent Span 80 (Sigma-Aldrich). The oxygen-sensitive dye, Pt(II) meso-Tetra(N-Methyl-4-Pyridyl)Porphine Tetrachloride, was purchased from Frontier Scientific .Krebs-Ringer bicarbonate solution (KRB), used for all perifusion analysis, contained 98.5 mM NaCl, 4.9 mM KCl, 1.2 mM potassium phosphate, 1.2 mM magnesium sulfate, 25.9 mM sodium bicarbonate, 2.6 mM CaClIslets were harvested from Sprague-Dawley rats  anesthetized by intraperitoneal injection of sodium pentobarbital (35 mg/230 g rat). All procedures were approved by the University of Washington Institutional Animal Care and Use Committee. Islets were prepared and purified as previously described 2 was pumped through the lower microchannel at 60 µL/hr and another aqueous mixture of culture media containing islets, alginate (1% wt ratio), and oxygen-sensitive dye (20 µM) was pumped through the upper microchannel at 70 µL/hr  prior to entering the perifusion dish. The perifusion system we have developed is similar to many standard systems Encapsulated islets were pipetted into a temperature-controlled, 250-µl perifusion dish , which was then sealed and mounted on to the stage of a Nikon Eclipse TE-200 inverted microscope. KRB was pumped through the dish at a flow rate of 150 µL/min using a Masterflex L/S peristaltic pump . To control gas tension in the perifusate, KRB flowed through an artificial lung consisting of 24 cm of gas-permeable silastic tubing  loosely coiled in a 125 mL glass bottle  containing indicated amounts of glucose, and incubated for 60 more min. At the end of this period, supernatant was assayed for insulin using an RIA kit .Insulin secretion rate was determined statically with multiple conditions as previously described The microcapsule size of the encapsulated islet is determined by the width of the outflow microchannel (180 µm). Thus, the thickness of the alginate layer surrounding the islet was the difference between the size of the islet and 180 µm. The alginate layer is nearly transparent, but was visible in images obtained with brightfield illumination ; no layeThe flow rates were adjusted so that coalescence of calcium-containing and islet-containing droplets would occur. In addition, the flow rates were kept low in order to avoid excessive shear stress. The maximal shear stress acting on the islets within the microfluidic chamber was estimated to be around 2.3 Pa /0.1 mm), which would occur at the outflow tube after the T-junction. This is in the same range as shear stress experienced by endothelial cells in vivo The oxygen tension around and in the islet is a balance between oxygen usage by the islets and its repletion via diffusion and flow. Decreasing flow from 180 to 50 µL/min resulted in an immediate decrease in oxygen tension, which was reversed after returning to the initial flow . Changin2, and either 21, 15, 10, 5, 3, or 1% O2 with balance N2 to the gas equilibration system. The oxygen signal reached steady state about 5 min after the change in oxygen . Consistent with OCR measurements, cellular respiration was responsible for the vast majority of the islet oxygen signal, since in the presence of KCN, islet oxygen was no longer sensitive to flow rate changes. Regarding the accuracy of the encapsulated sensor method to quantify changes in islet oxygen in response to agents, it is difficult to ascertain whether there are systematic errors. However, the responses to the three agents (as well as flow rate) indicate that the observed change in islet oxygen reflects changes in OCR by metabolically active islets. Moreover, responses to these three agents were observed in all six of the islet perifusions run with this protocol, illustrating the reliability of the measurement approach.The vast majority of islet studies are performed using media that is equilibrated with either 21% oxygen, or in order to prevent any effects of oxygen limitation, with 95% oxygen. However, physiological oxygen tensions in the islet are thought to range between 40 and 25 mm Hg. The perifusion system used permits the adjustment of islet oxygen either by choice of the oxygen content of the gas canister that is supplying the artificial lung, or by altering the flow rate of the perifusion. When the inflow perifusate was equilibrated with 21% oxygen, the islet oxygen ranged between 72 and 43 mm Hg, a little above what is physiologic. However, these values are integrated signals from the entire islet, and it is likely that oxygen at the core of the islet is much lower than this. It may be that conducting the experiment using oxygen tanks with a higher content of oxygen would give more robust results. It may also be useful to investigate the effects of compounds on changes in islet oxygen at different oxygen tensions.Oscillations in islet metabolism have been postulated to drive oscillations in calcium observed in mouse islets and oscillations in secretory function 2+–Ba2+ cross-linked alginate microcapsules and these cells remained viability for at least 110 days in the microcapsules Using microfluidics technology, we have presented a method for islet microencapsulation that appears to trap a fluorescent dye and support islet viability over a period of 2 days or more. The microfluid system we have used is particularly effective at generating and manipulating uniform micron-sized microcapsules. There are a number of options that could be considered with respect to optimizing the method, most importantly the choice of polymer layer. Alginate is widely used for cell immobilization and encapsulation because it is biocompatible and can be polymerized by simple gelation with divalent cations such as calcium. Since calcium can induce apoptosis in islets, however, it may be better to use zinc The microcapsule method that we have presented has utility as a general method for examining the effects of agents on OCR. Although a microsensor previously applied to islets appears to have greater temporal resolution than our method Our microcapsule sensor method, although complex relative to the oxygen consumption methods developed by BD Biosciences Click here for additional data file.Figure S1Steps involved in microdevice fabrication. See text in (TIF)Click here for additional data file.Figure S2A photo image of the microdevice used for encapsulation of islets. See text in (TIF)Click here for additional data file.


Neuroimaging studies provide evidence of cortical involvement immediately before and during gait and during gait-related behaviors such as stepping in place or motor imagery of gait. Here we attempt to perform single-trial classification of gait intent from another movement plan (point intent) or from standing in place. Subjects walked naturally from a starting position to a designated ending position, pointed at a designated position from the starting position, or remained standing at the starting position. The 700 ms of recorded electroencephalography (EEG) before movement onset was used for single-trial classification of trials based on action type and direction  as well as action type regardless of direction . Classification using regularized LDA was performed on a principal components analysis (PCA) reduced feature space composed of coefficients from levels 1 to 9 of a discrete wavelet decomposition using the Daubechies 4 wavelet. We achieved significant classification for all conditions, with errors as low as 17% when averaged across nine subjects. LDA and PCA highly weighted frequency ranges that included movement related potentials (MRPs), with smaller contributions from frequency ranges that included mu and beta idle motor rhythms. Additionally, error patterns suggested a spatial structure to the EEG signal. Future applications of the cortical gait intent signal may include an additional dimension of control for prosthetics, preemptive corrective feedback for gait disturbances, or human computer interfaces (HCI). The detection of locomotive intent has potential as a control signal in brain-computer interfaces, for mitigating complications in movement disorders, or for use in environments with human computer interfaces (HCI). Detection of this signal is valuable for spinal cord injury patients and other users of lower limb prosthetics or artificial exoskeletons. It may also prove useful for alleviating abnormal states that prevent proper gait coordination such as during freezing of gait in Parkinson's disease by providing preemptive visual cues that help prevent freezing episodes , is suitable for capturing the cortical dynamics of gait planning and production. EEG systems are also inexpensive compared to other imaging technologies and can be worn comfortably by the subject even during large-scale movements such as locomotion. There are many groups competing to produce commercial dry electrode EEG systems, including ones that wirelessly connect to cell phones   and beta (14–25 Hz) frequency band desynchronization over central motor and premotor areas (PMAs) as well as slow movement related potentials (MRPs) within single trials. Wavelets, especially the Debauchies (db) family, have been extensively used for EEG classification. The intended motor plan was predicted by classification of a principal components analysis (PCA) reduced feature space using regularized linear discriminant analysis (rLDA).Nine healthy, right-handed subjects  participated in the experiment. All subjects read and signed informed consent forms that were approved by the UCSD Human Research Protections Office. Subjects were naive and untrained in the task and no feedback was given that could cue subjects to modulate their cortical signals to produce better features over time.Continuous EEG was recorded from 64 Ag/AgCl electrodes positioned on a BioSemi nylon head cap according to the 10–20 International System. The signal was amplified with fixed gain BioSemi ActiveTwo amplifiers, band-passed from 0.2 to 100 Hz, and digitized at 512 Hz with 24-bit resolution. The independent software package DataRiver was used to read and record EEG signals as well as to integrate EEG signals with events from the Stim2007 stimulus presentation software  followed by a delayed go cue (indicated by an auditory tone of 1 s in duration). The command cues were 1 s in length, and an interval of 1 s occurred after the end of the command cue and before the sound of the go cue. For point and stand trials the end of the trial was indicated by an auditory tone 2 s after the go cue while for walk trials the same tone was sounded 4 s after the go cue Figure . The expAll data were analyzed offline. For artifact removal, data were high pass filtered above 1 Hz to remove slow cortical potentials and galvanic skin potentials. The experimenter first visually inspected the data for removal of noisy channels, epochs with artifacts, and epochs with incorrect responses or premature leg movement Figure . These dThe above channels and time points were noted and then excluded from original raw, unfiltered data for subsequent classification analyses. The number of trials remaining for each class and the number of channels remaining for each subject after artifact rejection are shown in Table Filtering of data provided to the classifier was explicitly avoided so as to avoid any misrepresentation or distortion of the signal. High pass and acausal filters are commonly used in EEG research to remove noise, but these are poor choices for predictive classification as they produce temporal smearing of the signal such that values at future time points in which actual movement occurs may be used in the calculation of values at time points of interest for movement prediction. Causal filters avoid this problem, but still cause distortions in the original signal.For classification, EEG data were separated into epochs starting 500 ms before and ending 200 ms after the onset of the go cue (but before the onset of gait) of each trial. We used this time range in order to capture the MRP signal from the motor cortex as well as any pre-movement related mu or beta desynchronization. Epochs were then processed to extract wavelet coefficients as the features for the classifier.Wavelets provide high-resolution frequency information at low frequencies and high-resolution time information at higher frequencies. Many biological signals consist of slow oscillating background activity with rapid onset of change in activity. The temporal dynamics of such frequency perturbations may be better captured by wavelets than other methods.d = n channels × 358 coefficients per trial. To facilitate classification by LDA, this high dimensionality was reduced by PCA to ten dimensions per trial  as the mother wavelet with periodization padding. The db family of wavelets has been shown to be better than biorthogonal wavelets, autoregressive filtering, and mu-matched filtering for extracting movement-related information from EEG signals  was trained on 10 features per trial using a 10-fold cross validation scheme  between the sample covariance matrix and spherical covariance matrix. Within each fold, the optimal value for the regularization constant k was chosen from 10 values covering the interval [0.09 0.5] based on the value with the highest performance in an inner 4-fold cross validation scheme that used training data only.In situations with few trials compared to features, we do not have enough data to accurately estimate the covariance matrices used by LDA. In the absence of adequate information, a spherical covariance matrix is often assumed. Regularization provides a way to smoothly interpolate  were visualized with respect to space  and frequency band (wavelet coefficients.) The topographies of the final weights were plotted at each frequency band as well as averaged over all frequency bands to pinpoint the channels that contributed most to classification. The absolute values of the final weights were plotted for each wavelet coefficient of each channel to visualize which region of the frequency spectrum was most informative for successful classification. Scalp topographies from each of the 10 PC components averaged over all 100-folds and all frequencies from the subject with the best performance were plotted in order of the PC with the highest contribution to LDA to the PC with the lowest to determine if PCs with higher eigenvalues contained the most pertinent information for classification.As an additional measure to assess the contribution of eye and muscle movements to the classification, LDA classification was performed using only EOG channels and those channels that would most be influenced by eye movements or muscle movements: Fp1, AF7, F7, FT7, T7, TP7, P9, P7, PO7, O1, Iz, Oz, O2, PO8, P8, P10, TP8, T8, FT8, F8, AF8, Fp2, and Fpz. These channels were located on the periphery of the EEG cap and were close to the origin of eye movements and muscles, and thus probably most strongly reflected the activity from these artifacts when compared to the other scalp channels.Subjects with greater than chance performance based on the average of 10 runs of 10-fold CV from a specified LDA classification using this subset of channels were eliminated from the reported grand averages over subjects for that classification.To determine if there was underlying spatial structure in the EEG signal, multiple discriminant analysis (MDA) using the one class vs. rest scheme was applied to the following classification problems: (1) left walk, front walk, right walk (three classes); (2) left point, front walk, right point (three classes); and (3) left walk, left point, right walk, right point (four classes). To visualize classification performance, trials from all cross validation folds were grouped based on true class and predicted class. For example, in a three-class problem, the groups were arranged into a 3 × 3 confusion matrix with row labels corresponding to true classes and column labels corresponding to predicted classes. Cells were normalized by dividing by the total number of trials in the row class, so that the value of one cell was the fraction of trials that the classifier predicted to be in the class as defined by the column location of the cell.Individual subject errors and errors averaged over all nine subjects are shown in Tables Only 9/162 classifications had significant performance using EOG and peripheral channels: L walk/F walk and R point/stand in subject 6; L point/R point in subject 9; walk/stand in subjects 1, 2, 4, 7; and point/stand in subjects 1 and 4. Within these nine classifications, the performance of EOG and peripheral channels was either poorer (8/9) or similar (1/9) to that of all scalp channels.t-tests using subject errors as samples, α = 0.05 and a mean set of 50% resulted in p-values below 0.05 for all 18 binary classifications. One-Way ANOVA testing suggested significant differences in means between the 15 classification problems that accounted for both direction and action (p = 0.035) and between the three classification problems that accounted for action only (p = 0.019). Post-hoc multiple comparisons test using Tukey's honestly different significance criterion both with and without assuming that the data followed a normal distribution revealed that only the mean error for walk vs. stand was significantly lower than the mean error for walk vs. point.Left tailed one-sample To pinpoint the origin and nature of the signal that the classifier was using, the contributions of different frequency ranges and channels were visualized by plotting the weightings by different PCs and the LDA classifier. The results for subject 4 (S4) and subject 8 (S8) in the two most difficult classifications, L walk/L point and R walk/R point, and in the three classifications collapsed across directions best provided insight into the classification process. Both subjects had significantly low errors for all classifications, but S4 probably had contributions from EOG or peripheral channels in the walk/stand and point/stand classifications while S8 had no such contributions. S8 had much higher error in the L walk/L point and R walk/R point classifications compared to S4.The frequency bands with the highest weighting were visualized by plotting the final weight for each of the 358 coefficients Figures , 3. The Using EOG and peripheral channels alone resulted in significantly low errors in the walk/stand and point/stand classifications in S4. Scalp topographies suggested weighting of the frontal electrodes in a pattern that suggested vertical eye movements, though this reliance on frontal electrodes was diminished in the walk/point classification. An example of possible neck muscle artifact can be seen in the scalp map for the 16–32 Hz frequency band of the R walk/R point classification. There were no scalp topographies with exclusively frontal or peripheral electrode weighting, which would suggest that eye or muscle movements were driving the classification.The most weighted PCs did not necessarily have the highest eigenvalues Figure . There wIn the confusion matrix for the three-class problem of left walk/front walk/right walk Figure , most leThis study demonstrated that single trial EEG data is (1) classifiable for walk intent before the onset of natural movement, (2) classifiable between two motor plans  that activate overlapping muscles, and (3) classifiable for an action at different target spatial locations. The largest contributors to successful classification were low frequencies (0–4 Hz) and channels located over areas involved in motor planning or motor production.It is important to note that “movement intent” as used in this paper refers to the preparation of a movement by the subject in response to an external experimental cue. Further, movement was elicited by a warning stimulus (S1) that was followed by an imperative stimulus (S2). The resultant MRP from this paradigm is the CNV, which contains contributions from both motor preparation and attention for the upcoming stimulus /event related synchronization (ERS), or the decrease/increase in power of mu (8–13 Hz) or beta (14–25 Hz) rhythms at somatotopically distinct regions before and during motor planning, action or imagery , medial primary motor cortex, and medial sensorimotor cortices. Cortical folding is different between individuals, which results in highly variable topographic distributions of useful EEG signal within a group of subjects. We created unsupervised custom spatial filters for each subject by including all noise-free channels available from the 64-channel montage covering the scalp and then applying PCA to transform and reduce this large feature space to the 10 dimensions with the most variance in the signal.The variable ranking of PCs by LDA weights was in line with a study of single trial EEG classification using PCA-reduced feature space and LDA for an imagined left-and-right hand movement task , leg motor area (CPz), and arm motor area (C4), which could explain the lower errors for the L walk/L point and R walk/ R point classifications compared with S8, who only had high weighting of channel C3. Notably, the classification error for walk/point was similar for both S4 and S8, possibly because more trials were available for training as the classification used trials from both left and right conditions.The dorsal premotor cortex (PMd) is postulated to be activated in externally cued movement preparation vs. movement that is internally driven by the subject, and vice versa in the SMA. Evidence for this has been circumstantial in humans, though one group demonstrated double-dissociation of PMd and SMA activity on MRPs by repetitive transcranial magnetic stimulation (rTMS) in humans during a right digit task in externally cued vs. internally driven conditions  locations using the same arm revealed an underlying structure in the pre-movement EEG signal that corresponded with target space  test set with an adequate number of trials to reliably assess the classifier accuracy, so we were not able to test this aspect.In conclusion, this study has shown that the EEG signal can be used for predictive classification between walk, point and stand actions as well between different target directions for these actions. Spatial and spectral contributions were from areas involved in motor planning or production and mostly from low frequency cortical activity, with smaller contributions from mu and beta frequency bands. It remains to be tested whether this signal can be detected in real-time non-stationary data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Facial clefts are extremely rare congenital deformities and there are only a few technique reports for surgical reconstruction of clefts in the literature. In this article, we report a Tessier no. 3 incomplete cleft reconstruction with alar transposition and irregular Z-plasty in a 2-year old female patient. Facial clefts are rare clinical entities observed with an incidence varying between 1.43 and 4.85 per 100,000 births. Other authors have reported an incidence of 9.5 to 34 per 1000 among all cleft cases . The aetIn 1976, Tessier classified the clefts between 0 and 14 based on the central facial landmarks . the nasomalar and the lid components separately as suggested by Mishra and Purwar [In a 2-year-old female patient consulted at our clinic due to facial deformity, a Tessier 3 facial incomplete cleft has been detected. The child born as the first child to unrelated healthy parents  through normal vaginal delivery was 51 cm and 3270 gr at birth. In the patient's history, there was no exposure to teratogens or any information pointing towards a genetic syndrome in the families of either parent. For the repair of the deformity in the patient, alar transposition flap  and irregular Z-plasty (for lid component) have been planned in an asymmetrical manner considering d Purwar  , (b) the cleft of the upper lip (Lip component), (c) and the gap between the nose and the malar area . Whatever method is chosen, we can confidently claim that these components must be taken into consideration during any repair. The repair in our patient was tried to be performed through alar transposition flap and irregular Z-plasty, considering the three main components as proposed by Mishra and Purwar  (the lipWe are of the opinion that the methods to be applied for the repair of clefts must be investigated in large study groups. Still, a clear treatment algorithm is truly difficult to describe for these rarely observed cases.