Bootstrap CI Research Articles

Adverse Childhood Experiences and Chronic Low Back Pain in Adulthood: Role of Emotion Regulation

Adverse childhood experiences (ACEs) can have profound deleterious effects on subsequent physical health and psychological functioning in adulthood. Commonly studied ACEs include childhood emotional, physical, sexual abuse, parental psychopathology, substance abuse, and early parental loss due to death/abandonment, or parental incarceration. Recent evidence suggests that ACEs represent a likely social determinant of chronic pain development in adulthood; however, little research to date has investigated the psychological processes that might underlie the link between ACEs and chronic pain. The current study examined emotion regulation as a potential mediator of the relationship between ACEs and pain severity in adults with chronic low back pain (cLBP). Study participants included 209 adults (54% women, 58% non-Hispanic Black) between the ages of 18 and 85 with cLBP. Participants retrospectively reported childhood experiences of abuse and neglect on the Adverse Childhood Experiences (ACEs) questionnaire. Higher ACEs scores are indicative of greater exposure to adverse childhood events. Participants also completed the Difficulties in Emotion Regulation Scale (DERS), and the Brief Pain Inventory – Short Form (BPI-SF) to assess cLBP severity. Sociodemographic data (e.g., sex/gender, ethnicity/race, age, social status) were also collected. In data analytic models, sociodemographic variables were included as covariates. Results revealed that emotion regulation mediated the relationship between ACEs and cLBP severity (indirect effect = .160, 95% percentile bootstrap CI [.071 to .270]). More specifically, ACEs were linked to greater difficulty with emotion regulation (p < .001), which, in turn, was associated with greater cLBP severity (p < .001). Results suggest ACEs may be linked to cLBP severity in adulthood though difficulties in emotion regulation. This aligns with research demonstrating that childhood maltreatment can lead to maladaptive emotion regulation strategies (heightened emotional reactivity, rumination, attentional bias to threats) which can exacerbate and perpetuate poor physical and mental health over the lifespan. Grant support from R01MD010441.

The relationship between ecological executive function and stigma among patients with epilepsy: The mediating effect of social support

ObjectiveStigma is a key determinant of mental health among patients with epilepsy (PWE). In prior work, many PWE have been found to exhibit impaired executive function (EF) and to lack sufficient social support. This study was developed to explore factors that may influence stigma in PWE with a focus on the associations among EF, social support, and stigma in this patient population. MethodsA questionnaire was administered to 121 patients with primary epilepsy as a means of collecting clinical and demographic details. The severity of EF impairment, social support levels, and stigma were analyzed using the Behavior Rating Inventory of Executive Function-Adult (BRIEF-A), the Social Support Rating Scale, and the Kilifi Stigma Scale for Epilepsy-Chinese (KSSE-C). Descriptive analyses were used to evaluate demographic details, and parameters associated with stigma were identified through multiple linear stepwise analyses. Spearman’s correlation analyses and moderated mediation analyses were utilized to examine relationships between impaired EF, social support, and stigma. Significant mediation effects were identified using the SPSS PROCESS macro via a bootstrap approach. ResultsUp to 95.9% of the 121 PWE in this study were affected by stigma, with differneces in stigma being associated with long-term residence (urban or rural), family monthly income, disease control status (controlled or uncontrolled), and medication types. Multiple stepwise linear regression analyses revealed that the number of years of education (t = - 4.58, P < 0.001), family monthly income per capita (t = −3.43, P = 0.001), and age of first episode (t = −2.71, P = 0.008) for PWE were negatively correlated with stigma scores, while long-term residence (t = 2.79, P = 0.006), course of disease (t = 3.65, P < 0.001), disease control (t = 2.79, P = 0.006), and types of medication (t = 2.73, P = 0.007) were positively correlated with stigma scores. Impaired EF was found to be significantly associated with stigma (β = 0.64, P < 0.001), and social support was able to mediate the association between stigma and impaired EF (β = 0.64, P < 0.001). Non-parametric bootstrap analysis results revealed the indirect impact of EF through social support (95% bootstrap CI = 0.11, 0.22), with the indirect influence of social support accounting for 44.3% of the overall effect of stigma. ConclusionsThese results offer new insight into the interactive mechanisms that underlie stigma and EF, in addition to clarifying the ability of social support to mediate this relationship. These data thus highlight valuable theoretical and methodological approaches to preventing stigma in PWE, suggesting that stigma in PWE can be effectively reduced by bolstering EF, and social support plays a mediating effect in this context.

Do Attitudes Toward Violence Affect Violent Behavior?

ABSTRACT Attitudes toward violence are important in theoretical explanations of violent behavior and efforts to reduce violent behavior. Though an association between attitudes and violent behavior has been demonstrated, most studies have used correlational/observational research designs. We conducted a randomized experiment to test the effect of attitudes toward violence on violent behavior with 285 men from the community. Participants were randomly assigned to receive material to make attitudes toward violence more negative or to a control condition. Violent behavior was then approximated by asking participants to select from a range of violent and nonviolent options in response to a series of interpersonal conflict vignettes. Participants in the negative attitude condition responded with less violence on the vignette questionnaire than did participants in the control condition (Cohen’s d = −0.23, 95% CI [−0.46, 0.01]). Participants also completed a measure of attitudes toward violence at the end of the experiment; more positive attitudes toward violence showed a strong association with more violent responding on the vignette questionnaire (r = .62, 95% bootstrapped CI [.54, .69]). Consistent with theory and practice, our findings suggest that attitudes toward violence may play a role in violent behavior.

Sedentary Behavior, Sleep Quality, and Subjective Memory Function in Middle-Aged Adults

The visible impact of the SDoHs on health and behavioral health as well as health disparities among minority populations is heightened due to COVID-19. One group about which little is known in relation to SDoHs is the older Korean immigrant population in the U.S. To examine the impact of SDoHs on the health, mental health, and health care utilization, a systematic review of studies focused on SDoHs for this population was conducted. Using multiple indexing terms, databases were searched for articles published in English between January 1, 2011 and December 2020. Articles were included in the search if they examined social determinants of health of older Korean immigrants defined as foreign-born Koreans aged 60 or older who live in the United States regardless of citizenship or legal immigration status. A total of 1090 articles were identified in the search. A review of abstracts for inclusion criteria resulted in 118 articles for review. Seventy-one articles were excluded during the review process. A total of 47 articles met inclusion criteria and were evaluated. The review revealed that SDoHs, including education level, financial resources, access to health insurance, level of acculturation and level of social support, influenced cognitive status, depressive symptoms, health status and quality of life. These findings validate the need for interventions to address the social care needs of older Korean immigrants and can be used to identify the role of social workers in addressing the SDoHs that result in health disparities for older Korean immigrants.

Benevolent Childhood Experiences and Depressive Symptoms Among Chinese Undergraduates: A Moderated Mediation Model Examining the Roles of Uncertainty Stress and Family Relationship.

Background: The evidence on the association between benevolent childhood experience (BCE) and depressive symptoms in students is complex. This study aims to explore the underlying mediation mechanism of BCE toward depressive symptoms and whether this link was moderated by the family relationship among Chinese undergraduates.Methods: From March 2021 to May 2021, a cross-sectional study was conducted in China, and 1821 undergraduates were recruited in this study. Participants were asked to complete a self-reported electronic questionnaire. The software SPSS PROCESS macro was used to test the mediation and mediated moderated modeling analysis.Results: Mediation analysis indicated that uncertainty stress (US) partly mediated the link between BCE and depressive symptoms (indirect effect = −0.47, 95% bootstrap CI = −0.55, −0.39). The indirect effect of the US accounted for 39.63% of the total variance in depression. Moderation analysis indicated that the association between the US and depressive symptoms was significantly modified by family relationships (interact effect = −0.019, P < 0.001). An integrative moderated mediation analysis indicated that the indirect effect from BCE to depressive symptoms through the US was also moderated by family relationships (interact effect = −0.012, P = 0.014).Conclusion: Uncertainty stress plays a key role in bridging BCE and depressive symptoms while the family relationship can buffer the impact of the US on depressive symptoms among Chinese undergraduates. Enhancing tolerance of uncertainty and improving family relationships are needed to protect undergraduates from depressive symptoms.

Factors influencing atrophy progression in primary progressive aphasia

AbstractBackgroundPrimary progressive aphasia (PPA) is a rare primarily language‐related neurodegenerative disorder that subdivides into the non‐fluent (nfvPPA) and the semantic variant (svPPA). Atrophy progression shows variant‐specific patterns, however, its extent seems highly individual and thus difficult to predict.MethodWe investigated volumetric changes in patients with nfvPPA (n=18) and svPPA (n=15) with an MRI scan (3D T1 MPRAGE sequence, 3T) at baseline and 2‐years follow‐up that were recruited from the prospective German FTLD‐consortium study. According to the LONI Probabilistic Brain Atlas (Shattuck et al., 2009), 56 brain regions were assessed with automated atlas‐based volumetry (Huppertz et al., 2010). Longitudinal volumetric changes were analyzed by means of the R software (www.r‐project.org). A possible impact of group, adjusted for age and sex, had been investigated using a linear mixed effect model. Atrophy progression for each region over two years was correlated (Pearson or Kendall rank correlation; 95% BCa bootstrap CI with 1000 replicates) with age at symptom onset, years of education, and disease duration to review a possible relation.ResultVolume change within 2‐years revealed parts of the left frontal lobe (up to ‐10%) and subcortical regions in nfvPPA and parts of the left temporal lobe (up to ‐15%) and the hippocampus/amygdala complex in svPPA as most progressive.A correlation analysis with age at symptom onset rendered no relevant results. Higher educated patients showed more atrophy in the right parahippocampal gyrus in nfvPPA and less atrophy in white matter portions of the left superior frontal, the bilateral middle and inferior frontal, the right middle and bilateral lateral orbitofrontal and the bilateral cingulate gyrus in svPPA. Shorter disease duration correlated with higher atrophy in the caudate and putamen in nfvPPA, and in the left middle and inferior temporal gyrus, the right superior and bilateral middle occipital gyrus, the left cuneus, and left angular gyrus in svPPA.ConclusionAge at symptom onset showed no interrelation with atrophy progression in PPA. Higher education levels seem to slow white matter decrease of frontal areas in svPPA. Shorter disease duration is related to increased volume loss in some primarily affected regions in both nfvPPA and svPPA.

A Mobile Intervention for Self-Efficacious and Goal-Directed Smartphone Use in the General Population: Randomized Controlled Trial.

BackgroundPeople spend large parts of their everyday life using their smartphones. Despite various advantages of the smartphone for daily life, problematic forms of smartphone use exist that are related to negative psychological and physiological consequences. To reduce problematic smartphone use, existing interventions are oftentimes app-based and include components that help users to monitor and restrict their smartphone use by setting timers and blockers. These kinds of digital detox interventions, however, fail to exploit psychological resources, such as through promoting self-efficacious and goal-directed smartphone use.ObjectiveThe aim of this study is to evaluate the theory-based smartphone app “Not Less But Better” that was developed to make people aware of psychological processes while using the smartphone and to support them in using their smartphone in accordance with their goals and values.MethodsIn a randomized controlled trial, effects of a 20-day intervention app consisting of five 4-day training modules to foster a goal-directed smartphone use were evaluated. In the active control condition (treatment as usual), participants received a digital detox treatment and planned daily time-outs of at least 1 hour per day. Up to a 3-week follow-up, self-reported problematic smartphone use, objectively measured daily smartphone unlocks, time of smartphone use, self-efficacy, and planning towards goal-directed smartphone use were assessed repeatedly. Linear 2-level models tested intervention effects. Mediation models served to analyze self-efficacy and planning as potential mechanisms of the intervention.ResultsOut of 232 enrolled participants, 110 (47.4%; 55 participants in each condition) provided data at postintervention and 88 (37.9%; 44 participants in each condition) at 3-week follow-up. Both conditions manifested substantial reductions in problematic smartphone use and in the amount of time spent with the smartphone. The number of daily unlocks did not change over time. Further, modelling changes in self-efficacy as a mediator between the intervention and problematic smartphone use at follow-up fit well to the data and showed an indirect effect (b=–0.09; 95% bias-corrected bootstrap CI –0.26 to –0.01), indicating that self-efficacy was an important intervention mechanism. Another mediation model revealed an indirect effect from changes in planning via smartphone unlocks at postintervention on problematic smartphone use at follow-up (b=–0.029, 95% bias-corrected bootstrap CI –0.078 to –0.003).ConclusionsAn innovative, theory-based intervention app on goal-directed smartphone use has been found useful in lowering problematic smartphone use and time spent with the smartphone. However, observed reductions in both outcomes were not superior to the active control condition (ie, digital detox treatment). Nonetheless, the present findings highlight the importance in promoting self-efficacy and planning goal-directed smartphone use to achieve improvements in problematic smartphone use. This scalable intervention app appears suitable for practical use and as an alternative to common digital detox apps. Future studies should address issues of high attrition by adding just-in-time procedures matched to smartphone users’ needs.Trial RegistrationGerman Clinical Trials Register DRKS00017606; https://tinyurl.com/27c9kmwy

Avoiding Time-Related Biases: A Feasibility Study on Antidiabetic Drugs and Pancreatic Cancer Applying the Parametric g-Formula to a Large German Healthcare Database.

PurposeInvestigating intended or unintended effects of sustained drug use is of high clinical relevance but remains methodologically challenging. This feasibility study aims to evaluate the usefulness of the parametric g-formula within a target trial for application to an extensive healthcare database in order to address various sources of time-related biases and time-dependent confounding.Patients and MethodsBased on the German Pharmacoepidemiological Research Database (GePaRD), we estimated the pancreatic cancer incidence comparing two hypothetical treatment strategies for type 2 diabetes mellitus (T2DM), i.e., (A) sustained metformin monotherapy vs (B) combination therapy with DPP-4 inhibitors after one year metformin monotherapy. We included 77,330 persons with T2DM who started metformin therapy at baseline between 2005 and 2011. Key aspects for avoiding time-related biases and time-dependent confounding were the emulation of a target trial over a 7-year follow-up period and application of the parametric g-formula.ResultsOver the 7-year follow-up period, 652 out of the 77,330 study subjects had a diagnosis of pancreatic cancer. Assuming no unobserved confounding, we found evidence that the metformin/DPP-4i combination therapy increased the risk of pancreatic cancer compared to a sustained metformin monotherapy (risk ratio: 1.47; 95% bootstrap CI: 1.07–1.94). The risk ratio decreased in sensitivity analyses addressing protopathic bias.ConclusionWhile protopathic bias could not fully be ruled out, and computational challenges necessitated compromises in the analysis, the g-formula and target trial emulation proved useful: Self-inflicted biases were avoided, observed time-varying confounding was adjusted for, and the estimated risks have a clear causal interpretation.

Kinematic analysis of movement impaired by generalization of fear of movement-related pain in workers with low back pain.

PurposeTo identify impaired trunk movement during work-related activity in individuals with low back pain (LBP) and investigate whether abnormalities were caused by generalized fear of movement-related pain.MethodsThis cross-sectional study was conducted at a hospital in Japan. We recruited 35 participants with LBP (LBP group; 26 males, 9 females) and 20 healthy controls (HC group) via posters at our hospital. The task required lifting an object. We used a 3D motion capture system to calculate the peak angular velocity of trunk flexion and extension during a lifting task. Pain-related factors for the LBP group were assessed using the visual analogue scale (VAS) for pain intensity over the past 4 weeks and during the task, the Tampa Scale for Kinesiophobia (TSK), the Pain Catastrophizing Scale (PCS), and the Pain Anxiety Symptoms Scale-20 (PASS-20). We compared kinematic variables between groups with a generalized linear mixed model and investigated the relationship between kinematic variables, VAS scores, and psychological factors by performing a mediation analysis.ResultsThe peak angular velocity of trunk extension showed significant main effects on the group factors (LBP group vs. HC group) and their interactions; the value of the kinematic variable was lower at Trial 1 in the LBP group. No LBP participant reported pain during the experiment. The mediation analysis revealed that the relationship between the VAS score for pain intensity over the past 4 weeks and the peak angular velocity of trunk extension in the first trial was completely mediated by the TSK (complete mediation model, 95% bootstrapped CI: 0.07–0.56).ConclusionIndividuals with LBP had reduced trunk extension during a lifting task. Generalized fear of movement-related pain may contribute to such impaired trunk movement. Our findings suggest that intervention to ameliorate fear of movement may be needed to improve LBP-associated disability.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials.

Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Condition or cognition? Mechanism of change in fatigue in a randomized controlled trial of graded exercise therapy or cognitive behavior therapy for severe fatigue in patients with advanced cancer.

Fatigue remains one of the most common and distressing symptoms during treatment for advanced cancer. The TIRED trial demonstrated cognitive behavior therapy's (CBT) significant and clinically relevant effects to reduce fatigue among patients with advanced cancer, while graded exercise therapy (GET) did not prove beneficial. The present study aims to determine the mechanisms by which CBT and GET affect fatigue. The TIRED trial randomized 134 patients with advanced cancer to CBT (n = 46), GET (n = 42), or usual care (n = 46). At 14 weeks, 126 evaluable patients provided fatigue data and of those 117 received ≥1 CBT or GET session or usual care. We tested a prespecified multiple mediation model with four potential mediators (physical activity, exercise capacity, self-efficacy, and fatigue catastrophizing) assessed at baseline and at 14 weeks. Post-hoc analyses also included perceived physical activity and emotional functioning as potential mediators. A total of 82 of 117 patients completed all required measures. CBT reduced fatigue indirectly through its effect on self-efficacy, ab = -3.292; 97.5% bootstrap CI [-6.518 to -0.598]. CBT participants experienced an increase in fatigue self-efficacy, with greater self-efficacy associated with decreased fatigue severity. There was no evidence that changes in physical activity, exercise capacity, perceived physical activity, fatigue catastrophizing, or emotional functioning mediated CBT's or GET's effects on fatigue. The effect of CBT was attributable to changes in cognition, that is, increased self-efficacy led to reduced fatigue severity. No significant mediators for GET were found. The findings inform further refinement of interventions for fatigue in this seriously ill population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cadaveric study investigating the phrenic-sparing volume for anterior suprascapular nerve block

BackgroundThis cadaveric study investigated the maximum effective volume of dye in 90% of cases (MEV90), required to stain the suprascapular nerve while sparing the phrenic nerve during the performance of...

Cadaveric investigation of the minimum effective volume for ultrasound-guided suprainguinal fascia iliaca block

BackgroundThis cadaveric dose-finding study investigated the minimum effective volume of dye in 90% of cases (MEV90), required to stain the femoral, lateral femoral cutaneous and obturator nerves for ultrasound-guided suprainguinal...

Does the working alliance mediate the therapist competence-outcome relationship in cognitive behavior therapy for depression?

Objective: This study examined whether the working alliance mediated the effect of therapist competence on subsequent depression symptomology during Cognitive Behavioral Therapy (CBT). We also tested the potential moderation effect of alliance on subsequent depressive symptomology, based on participants’ cognitive aptitude. Method: A total of 86 sessions were coded as the prediction interval across 50 patient-therapist dyads (age M = 39.22, SD = 8.78; 76% female). While accounting for prior depression, competence, and alliance levels, predictors were assessed early treatment (session 1; n = 45 sessions), mid-treatment (session 12; n = 41 sessions), and depressive symptomology was assessed at the subsequent session to the predictor assessments to investigate within-session variability of process variables. Results: Mediation analysis revealed that the effect of early treatment therapist competence on symptom change was mediated by alliance (indirect effect: β = −.17, 95% percentile bootstrap CI [−.32, −.01]). The positive association involving early treatment alliance and next session outcome was conditional upon low cognitive aptitude levels. Conclusions: Our result offers preliminary support for alliance as a mediator of the effect of competence, and that alliance-outcome relations vary as a function of client aptitude. These novel findings require replication and extension.

Frailty at Risk Scale (FARS): development and application.

The aim of this cross-sectional study was to develop a Frailty at Risk Scale (FARS) incorporating ten well-known determinants of frailty: age, sex, marital status, ethnicity, education, income, lifestyle, multimorbidity, life events, and home living environment. In addition, a second aim was to develop an online calculator that can easily support healthcare professionals in determining the risk of frailty among community-dwelling older people. The FARS was developed using data of 373 people aged ≥ 75years. The Tilburg Frailty Indicator (TFI) was used for assessing frailty. Multivariate logistic regression analysis showed that the determinants multimorbidity, unhealthy lifestyle, and ethnicity (ethnic minority) were the most important predictors. The area under the curve (AUC) of the model was 0.811 (optimism 0.019, 95% bootstrap CI = -0.029; 0.064). The FARS is offered on a Web site, so that it can be easily used by healthcare professionals, allowing quick intervention in promoting quality of life among community-dwelling older people.

Sedentary time is related to deficits in response inhibition among adults with overweight and obesity: An accelerometry and event-related brain potentials study.

Excessive sedentariness has been related to poorer cognitive control in adults. Sedentariness may compound obesity-related impairments in response inhibition, but its relationship to response inhibition remains poorly understood. This study investigated the relationship between accelerometer-measured sedentary time (ST, min/day), performance on the Oddball and NoGo tasks, N2 and P3-ERP indices of response inhibition and attentional control in 80 adults with overweight and obesity (55 females, Mage =35.2±5.8years, BMI=32.8±5.3kg/m2 ). ST was not related to performance on the Oddball task. However, more sedentary adults had larger P3b amplitude to targets. Higher ST was also related to increased attentional resource allocation during NoGo target and nontarget trials as indicated by higher P3b amplitudes across centroparietal sites (C1, Cz, C2, CP1, CPz, CP2; ps≤.03). ST was negatively indirectly related to target accuracy on NoGo trials through its association with faster response times to nontargets (95% percentile bootstrap CI for a standardized effect: -0.182, -0.014). ST was not related to N2 amplitude on either Oddball or NoGo target trials. Adjustment for moderate-to-vigorous physical activity (MVPA; all models), age (models with P3b NoGo target amplitude, N2 NoGo target amplitude and latency), and % fat mass (models with target NoGo accuracy and N2 NoGo target amplitude) did not modulate behavioral findings. MVPA did not significantly predict P3b amplitude. Our results suggest suboptimal response inhibition due to trading accuracy for speed and despite the upregulation of attentional resources among more sedentary adults with overweight and obesity.

253 Better and faster automatic sleep staging with artificial intelligence

Abstract Introduction Sleep staging of polysomnography (PSG) is a time-consuming task, it requires significant training, and significant variability among scorers is expected. A new software (MEBsleep by Medibio Limited) was developed to automatically perform sleep scoring based on machine learning algorithms. This study aimed to perform an extensive investigation of its agreement with expert sleep technicians. Methods Forty polysomnography recordings of patients that were referred for sleep evaluation to three sleep clinics were retrospectively collected. Three experienced technicians independently staged the recording complying with the scoring rules of the American Academy of Sleep Medicine guidelines. Positive Percent Agreement (PPA), Positive Predictive Value (PPV), and other agreement statistics between the automatic and manual staging, among the staging performed by the three technicians, and their differences were calculated. Bootstrap resampling was used to calculate 95% confidence intervals and statistical significance of the differences. Results Automatic staging took less than two minutes per PSG on a consumer laptop. The automatic staging resulted for the most comparable (PPA difference of N1, N3, and REM; PPV difference of N1, N2, N3, and REM) or statistically significantly more in agreement with the technicians’ staging than the between-technician agreement (PPA difference of N2: 3.90%, 95% bootstrap CI 1.79%-6.01%; PPV difference of Wake: 1.16%, 95% bootstrap CI 0.64%/1.67%), with the sole exception of a partial reduction in the positive percent agreement of the Wake stage (PPA difference of Wake -7.04%, 95% bootstrap CI -10.40%/-3.85%). The automatic staging also demonstrated very high accuracy in an indirect comparison with other similar software. Conclusion Given these promising results, the use of this software may support sleep clinicians by improving efficiency in sleep scoring. Support (if any):

406 Clinical Validation of AI Scoring in Adult and Pediatric Clinical PSG Samples Compared to Prospective, Double-Blind Scoring Panel

Abstract Introduction Despite an appreciable rise in sleep wellness and sleep medicine A.I. research publications, public data corpuses, institutional support, and health A.I. research funding opportunities, the availability of controlled-retrospective, hybrid-retrospective-prospective, and prospective-RCT quality clinical validation study evidence is limited with respect to their potential clinical impact. Furthermore, only a few practical examples of A.I. technologies are validated, in use today clinically, and widely adopted, to assist in sleep diagnoses and treatment. In this study, we contribute to this growing body of clinical A.I. validation evidence and experimental design methodologies with an interoperable A.I. scoring engine in Adult and Pediatric populations. Methods Stratified random sampling with proportionate allocation was applied to a database of N&amp;gt;10,000 retrospective diagnostic clinical polysomnography (PSG), selected by evidence grading standards, with controls applied for OSA severity, diagnoses; sleep, psychiatric, neurologic, neurodevelopmental, cardiac, pulmonary, metabolic disorders, medications; benzodiazepines, antidepressants, stimulants, opiates, sleep aids, demographic groups of interest; sex, adult age, pediatric age, BMI, weight, height, and patient-reported sleepiness, to establish representative N=100 Adult and N=100 Pediatric samples. Double Blinded scoring was prospectively collected for each sample by 3 experienced RPSGT certified sleep technologists randomized from a pool of 9 scorers. Sensitivity (PA), Specificity (NA), Accuracy (OA), Kappa (K), and 95% Bootstrap CI’s are presented for sleep stages, OSA/CSA, hypopnea 3%/4%, arousals, limb movements, Cheyenne-Stokes respiration, periodic breathing, atrial fibrillation, and other events, and normative, mild, moderate, and severe OSA categories for global-AHI and REM-AHI. Results for Sleep Staging and OSA Severity Diagnostic Accuracy are summarized. Results A.I. scoring performance meet but in most cases exceeded initial clinical validation study (N=72 Adults, 2017) PA, NA, OA, K point-estimates and confidence-interval results for the 26 event types and 8 AHI-categories evaluated. The Adult sample showed 87%/94% Sensitivity/Specificity across all stages (Wake/N1/N2/N3/REM) and 94%/96% Sensitivity/Specificity for AHI&amp;gt;=15. The Pediatric sample showed 87%/93% Sensitivity/Specificity staging, 89%/98% Sensitivity/Specificity AHI&amp;gt;=15. Observed Accuracy was &amp;gt;90% for Adults and Pediatrics all 26 events and 7 AHI-categories analyzed, except REM-AHI&amp;gt;=5 (85%/82% Adults/Pediatrics). Conclusion We provide clinical validation evidence that demonstrates interoperable A.I. scoring performance in representative Adult and Pediatric patient clinical PSG samples when compared to prospective, double-blind scoring panel. Support (if any):

The role of anxiety and depression in the relationship between physical activity and sleep quality: A serial multiple mediation model

BackgroundPhysical inactivity exacerbates poorer sleep quality, but potential underlying mechanisms of this association remain unknown. The present study aims to disentangle the pathways linking psychical activity to sleep quality through the serial mediation effect of anxiety and depression in a Chinese population. MethodsData analyzed were from Guangdong Sleep and Psychosomatic Health Survey, a cross-sectional population-based study with a representative sample of adult inhabitants aged 18-85 years living in Guangdong province, China. A total of 13,768 participants were included with the response rate of 80.4%. Singe and serial mediation analyses were conducted to examine whether anxiety and depression mediated the relationship between physical activity and sleep quality, independently and jointly. ResultsBoth direct and indirect effects of physical activity on sleep quality were found. As predicted, anxiety and depression mediated the relationship between physical activity and sleep quality (B Anxiety = -0.17, 95% bootstrap CI: -0.20 to -0.15; B Depression= -0.25, 95% bootstrap CI: -0.28 to -0.21), respectively. In addition, serial mediation analyses indicated that the association of physical activity and sleep quality is mediated by anxiety and depression in a sequential manner (B = -0.13, 95% bootstrap CI: -0.15 to -0.11). LimitationsThe primary limitation of the study is the cross-sectional design, which limits the causal inference ability. ConclusionsThese findings highlight the role of anxiety and depression as serial mediators of the relationship between physical activity and sleep quality. Thus, exercise-based programs focusing on improving sleep could benefit from a multi-faceted approach therapeutically targeting psychiatric disorders.

Social cognition as a mediator between cognitive reserve and psychosocial functioning in patients with first episode psychosis

IntroductionSocial cognition has been associated with functional outcome in patients with first episode psychosis (FEP). Social cognition has also been associated with neurocognition and cognitive reserve. Although cognitive reserve, neurocognitive functioning, social cognition, and functional outcome are related, the direction of their associations is not clear.ObjectivesThe aim of the study was to analyze the influence of social cognition as a mediator between cognitive reserve and cognitive domains on functioning in FEP both at baseline and at 2 years.MethodsThe sample of the study was composed of 282 FEP patients followed up for 2 years. To analyze whether social cognition mediates the influence of cognitive reserve and cognitive domains on functioning, a path analysis was performed. The statistical significance of any mediation effects was evaluated by bootstrap analysis.ResultsAt baseline, as neither cognitive reserve nor the cognitive domains studied were related to functioning, the conditions for mediation were not satisfied. Nevertheless, at 2 years of follow-up, social cognition acted as a mediator between cognitive reserve and functioning. Likewise, social cognition was a mediator between verbal memory and functional outcome. The results of the bootstrap analysis confirmed these significant mediations (95% bootstrapped CI (−10.215 to −0.337) and (−4.731 to −0.605) respectively).ConclusionsCognitive reserve and neurocognition are related to functioning, and social cognition mediates in this relationship.DisclosureThis work was supported by the Carlos III Institute of Health and European Fund for Regional Development (PI08/1213, PI11/ 01977, PI14/01900, PI08/01026, PI11/02831, PI14/01621, PI08/1161, PI16/ 00359, PI16/01164, PI18/00805), the Basque Foundation for He