There is a growing body of literature that suggests a linkage between impaired auditory function, increased listening effort, and fatigue in children and adults with hearing loss. Research suggests this linkage may be associated with hearing loss–related variations in diurnal cortisol levels. Here, we examine variations in cortisol profiles between young adults with and without severe sensorineural hearing loss and examine associations between cortisol and subjective measures of listening effort and fatigue.n = 8 per group) of adults enrolled in audiology programs participated, 1 group of adults with hearing loss (AHL) and 1 matched control group without hearing loss. Salivary cortisol samples were collected at 7 time points over a 2-week period and used to quantify physiological stress. Subjective measures of listening effort, stress, and fatigue were also collected to investigate relationships between cortisol levels, perceived stress, and fatigue.This study used a repeated-measures, matched-pair design. Two groups (Subjective ratings revealed that AHL required significantly more effort and concentration on typical auditory tasks than the control group. Likewise, complaints of listening-related fatigue were more frequent and more of a problem in everyday life for AHL compared to the control group. There was a significant association between subjective ratings of listening effort and listening-related fatigue for our AHL, but not for the control group. In contrast, there was no significant difference in cortisol measures between groups, nor were there significant associations between cortisol and any subjective measure.Young AHL experience more effortful listening than their normal hearing peers. This increased effort is associated with increased reports of listening-related fatigue. However, diurnal cortisol profiles were not significantly different between groups nor were they associated with these perceived differences. For some individuals with hearing loss, the simple act of listening can be mentally demanding. Those with hearing loss may be required to expend greater effort listening and devote more cognitive resources to listening than individuals without hearing loss . This iscortisol awakening response (CAR). In typical adults and children, the CAR often results in a doubling of cortisol levels within the first 30 min after wakening, and as discussed below, variations in the CAR have been associated with a variety of psychological and physiological disorders. Following this peak, cortisol levels steadily decrease as the day wears on and rise again during sleep  with a larger difference in cortisol levels between the FM and no-FM conditions posttesting. That is, when completing testing without the FM system activated, cortisol levels increased over the course of testing. However, when the children were tested using the FM system  levels decreased slightly, suggesting a reduction in listening-related stress with an improvement in signal-to-noise ratio provided by the FM system.Research suggests that, compared to peers without hearing loss, individuals with hearing loss may experience increased stress due, in part, to more frequent effortful listening . Howevern = 10) and without (n = 10) hearing loss. Participants in the study of Kramer et al. completed two speech tests, one in quiet and one in noise. Salivary cortisol samples were obtained at four time points: once before testing started, two more times during speech testing, and once after each speech task. After completing both speech tasks, all participants completed a visual linguistic closure test. The fourth saliva sample was obtained after this visual task. In contrast to the study of n = 10 per group). The first sample was collected in the morning (about 9:00 a.m.), and the second was collected near the end of the school day (about 2:00 p.m.). Average cortisol levels based on AUC measures were higher for the children with hearing loss compared to the control group, although the differences were not statistically significant. However, because only two samples per day were collected, this provided only a gross measure of cortisol production and did not allow examination of the CAR. In more recent work, n = 32) had significantly elevated cortisol levels upon awakening and a shallower CAR compared to the control group (n = 28). The authors suggest the higher cortisol levels at awakening and a suppressed CAR support the hypothesis that children with hearing loss experience higher stress during the day and may be at an increased risk for stress-related disorders. This hypothesis is also supported by recent work showing that adults and children with hearing loss experience increased fatigue compared to control groups and/or normative data , and fatigue. Our target populations were college-age adults with severe-to-profound hearing loss and a matched control group of adults without hearing loss. We focused on this group because (a) to date, there has been no work using salivary cortisol to assess listening-related stress and fatigue in college-age adults with hearing loss (AHL) and (b) college-age students may have an increased risk for listening-related stress and fatigue. For example, as mentioned above, Our primary research questions were as follows: (a) Compared to college-age adults with no hearing loss, does severe–profound hearing loss affect biological stress, as measured via cortisol levels? (b) Are there associations between cortisol levels and subjective ratings of stress, effort, and fatigue in this group? To answer these questions, salivary cortisol samples were collected throughout the day and used to evaluate overall cortisol production , cortisol levels upon awakening, and the CAR. In addition, subjective questionnaires were used to compare stress, effort, and fatigue between groups.n = 6), FM system (n = 4), note taker (n = 1), or preferential seating (n = 4).All procedures were reviewed and approved in accordance with Vanderbilt University Institutional Review Board (IRB 130773). A total of 16 adults, with and without hearing loss, participated in this study see . Eight pIn addition, a matched-pair control group (seven women) was created by having each participant with hearing loss recruit a control participant  from their own cohort of AuD students. The mean age of the control group was 24.0 years (range: 22–31 years). All control group participants had audiometric thresholds of < 20 dB HL at 500, 1000, 2000, and 4000 Hz.Exclusionary criteria included (a) taking medications that affect the substances that stimulate the HPA axis ; (b) taking medications that influence the subjective experience of stress, novelty, threat, or pain ; (c) taking medications that may influence salivary composition ; (d) taking oral, nasal, topical, or ophthalmic corticosteroids ; (e) having a learning disability; and (f) having a chronic medical condition that affects stress or fatigue .Seven samples were assayed from each participant. All samples were self-collected. All participants were provided directions on how to use the sample collection device from the manufacturer of the device (Esoterix). Samples were collected at “wake time” (T0), defined as the moment the participant opened their eyes and before their feet touch the ground, or when they opened their eyes and were ready to get up, or as soon as they were aware of being awake for the day and would not go back to sleep. Subsequent samples were taken 30–45 min after “wake time” (T1) and 12 hr after waking (T2) to allow for an AUC calculation. This protocol was repeated on the same day of the week, 1–2 weeks later. In addition, to capture potential differences in specific stress event–related fluctuations in cortisol levels, all participants provided a single saliva sample taken within 10 min after completing a graduate-level lecture that lasted at least 60 min. Because cortisol levels can vary in novel versus familiar situations e.g., , particiAt the end of each saliva collection day, participants completed a series of online questionnaires assessing their stress, listening effort, and fatigue. Responses were entered and managed using REDCap electronic data capture tools hosted at Vanderbilt University . Subjectalmost never or no effort and 3 = almost always or very much effort for the frequency and effort items, respectively. Items were summed to create an overall “frequency of listening demands” and “effort in listening” scores. Scores ranged from a minimum of 0  to a maximum score of 15 .Finally, given the association between perceived listening effort and fatigue , particir is reported for planned comparisons where an r of .10, .30, or .50 represent a small, medium, or large effect, respectively  = 0.001, p = .97, r = .008. Therefore, we used data from each time point on both days in a repeated-measures fashion to provide more stable estimates of cortisol changes over time. A series of repeated-measures ANOVAs were used to examine differences in salivary cortisol levels upon awakening, the slope of the CAR, and total salivary cortisol production between groups (adults with and without hearing loss). Overall salivary cortisol output was estimated for each test day using AUC. An AUC for each participant was calculated using salivary cortisol levels obtained upon awakening (T0), 30–45 postawakening (T1), and 12 hr postawakening (T2). The AUC was calculated using Formula 1 from Cortisol data were first converted from μg/dL to the more traditional unit nmol/L. The distribution of cortisol levels is positively skewed; therefore, values were log-transformed (base 10) before analyses . An effeectively . A preliF = 0.13, p = .73, r = .095  = 15.1, p = .002, r = .72, with mean cortisol levels, averaged across groups, increasing postawakening by approximately 50%. Specifically, mean cortisol levels, averaged across groups, increased from approximately 10.0 to 15.0 nmol/L when measured at awakening (T0) and again at 30–45 min postawakening (T1), respectively. However, there was no main effect of group, F = 0.35, p = .57, r = .15, and in contrast to that of F = 0.012, p = .91 , sample time point (T0 and T1), and group (CI users and adults without hearing loss). The CAR is evidenced in the change in cortisol levels from T0 (awakening level) to T1 (30–45 min postawakening). Prior work by  .91 see .F = 0.77, p = .40, r = .23.In addition, we completed a mixed-model ANOVA on AUC data to compare overall cortisol production between groups. Results revealed no significant difference in overall salivary cortisol production between our hearing loss group (1.98 nmol/L) and the control group (2.05 nmol/L), t test revealed no significant differences, t(7) = 0.28, p = .79, r = .10, in cortisol levels of AHL (M = 0.46 nmol/L) and their matched pairs (M = 0.42 nmol/L).Finally, to explore between group differences in response to a potential stress-inducing event, we compared cortisol levels obtained immediately after participants with hearing loss and their matched pair completed a 60-min graduate-level course. A paired-samples ps > .05) for any of these MacArthur measures. To compare participants' perceptions of happiness, anxiety, stress upon awakening, and the stress of a primary event, we first compared ratings across saliva collection days. Results of a series of Wilcoxon signed-ranks test revealed no significant difference across days , so ratings were summed to create a composite score. A series of Mann–Whitney tests using composite scores indicated that our participants with hearing loss felt no more anxious , excited , busy , or stressed  compared to our control group.Responses to MacArthur Salivary Cortisol Protocol questions were used to assess differences in participant psychological state and characteristics of their primary stress event on saliva sample collection days. A series of mixed-model, repeated-measures ANOVAs were used to make between-groups (hearing loss vs. no hearing loss) comparisons of participants wake times and the time of day and duration of their primary stressful event. Results revealed no main effect of Group or Significant Group × Day interactions . However, effort ratings on the first sample day (Mdn = 6.5) were significantly higher  than those obtained on the second sample day (Mdn = 4.0). Therefore, we analyzed between-groups effort ratings and for consistency frequency ratings, separately for each sample day. A series of Mann–Whitney U tests revealed no significant difference in frequency of listening demands between groups . However, ratings of the amount of effort required on listening tasks were significantly higher on both days  for the hearing loss group  compared to their age-matched controls without hearing loss . We used responses from a modified version of the Amsterdam Checklist for Hearing and Work to compare “frequency of listening demands” and “effort in listening” between AHL and their matched pairs. We first used a Wilcoxon signed-ranks test to compare summed scores obtained on the first and second sample days. There was no difference in the frequency of listening demands between days  or vigor  were observed; therefore, ratings were collapsed across days for subsequent analyses. Next, we used a series of Mann–Whitney U tests to compare ratings of fatigue and vigor between our hearing loss and control participants . It is worth noting that the fatigue and vigor ratings of both groups in the current study are quite similar to existing normative data for college-age adults  they were physically and emotionally tired to a greater extent due to difficulty in listening  than their matched pairs . Also, compared to their matched controls, CI users reported that fatigue and low energy due to difficulty in listening were more of a major problem in their lives . It is worth noting that all eight participants without hearing loss responded “not at all” (0) to this question. In contrast, responses from adults with severe hearing loss varied from “not at all” (0) to “quite a bit” (3) with a median response rating of 1.5 (between “a little” and “moderately”). Finally, AHL also reported they were more often physically and emotionally tired due to difficulty in listening  compared to their matched pairs . The range of responses to our listening-related fatigue questions, as a function of group, is shown in A series of Mann–Whitney ps > .05).We used a series of Spearman rank correlations to examine associations between our various physiological measures of stress  and subjective ratings of effort (Amsterdam effort questions) and general fatigue and vigor (POMS ratings). We quantified the CAR as the difference in cortisol levels obtained 30–45 min postawakening and levels obtained upon awakening . Association between cortisol measures and listening-related fatigue were explored using responses from our three listening fatigue questions. Listening effort ratings from sample collection Day 1 and Day 2 were analyzed separately given the significant difference in perceived effort between days (see the Listening-Related Fatigue section). Given the pilot nature of our study, we chose to explore these relevant associations without controlling for potential inflation of Type 1 errors. Despite this liberal criterion, results of these exploratory analyses revealed no significant correlation between any cortisol measure and any subjective measure of effort or fatigue  but not for their matched controls without hearing loss . Specifically, listening demands were positively correlated with the degree to which difficulty in listening causes an individual to become physically or emotionally tired ; with how much a problem fatigue and low energy due to difficulty in listening is in an individual's life  and with how often a person felt physically or emotionally tired due to difficulty in listening .Prior research suggests an association between perceived listening effort in daily settings and ratings of long-term general fatigue . TherefoListening-related fatigue in AHL is poorly understood. In the primary authors' day-to-day interactions with AHL, a common report is how physically and mentally drained individuals with hearing loss are as a result of day-to-day interactions. This is of importance to the field of audiology if increased listening effort, stress, and subsequent fatigue lead to frequent activation of the HPA axis. Chronic activation has been implicated in the development of significant health conditions, including metabolic syndrome, cardiovascular disease, cognitive decline, and a variety of mood disorders and functional illnesses. The purpose of this research was to examine whether adults with severe hearing loss experience more physiological stress, as quantified by various cortisol measures  and greater fatigue than adults without hearing loss. A secondary purpose was to examine potential associations between various cortisol measures and subjective measures of listening effort and fatigue.In contrast to our predictions, average awakening cortisol levels in our AHL group were slightly lower than cortisol levels for the normal hearing (NH) group, although the difference was not statistically significant. Likewise, no statistical differences in the CAR or AUC between groups were observed. Our findings are in line with the findings of hr postwakening) were quite sparse and thus not optimal for assessing the CAR. It is possible that collecting more samples during the day would increase our ability to precisely measure differences in cortisol levels between groups, should they exist. this study and that of n = 10 participants/group) could limit our ability to detect significant differences between groups. Given our small sample size, effect sizes of 1.49 or larger would be needed to achieve adequate statistical power (80%). According to d = 0.2, 0.5, and 0.8, respectively, so our sample would be sensitive to only extremely large group differences.The lack of significant differences in cortisol measures between our groups of college-age participants may suggest that salivary cortisol, a physiological measure of stress thought to be associated with fatigue, is not sensitive enough to detect hearing loss–related stress in successful CI users, should they exist, in this age group. However, given the pilot nature of this study, it is important to acknowledge limitations that could have also affected our outcomes. For example, our cortisol sampling intervals . It is intuitive to think that if these difficult listening situations were very stressful and fatiguing that these individuals would have ultimately chosen different career path. Selecting a group more representative of the general population might also yield different results.Finally, it is worth noting that, should these results be replicated in a much larger sample, the lack of a significant difference is an extremely positive finding. Such a result suggests that the increased listening effort commonly experienced by people with hearing loss may not universally contribute to increased physiological stress and its concomitant negative effects.SDs from mean values, between groups. Importantly, they found AHL were more than twice as likely to experience severe fatigue and more than 4.5 times as likely to report severe vigor deficits. Interestingly, no AHL in the current study reported severe fatigue or vigor problems.A secondary aim of this pilot study was to examine subjective ratings of effort and fatigue in our sample and to investigate associations between cortisol levels, our physiological measure of stress, and these subjective measures. We did this using a generic measure of fatigue and vigor (POMS) and subjective scales focused on listening effort and listening-related fatigue . In the current study, although AHL reported expending more “listening effort” than our control group, generic ratings of fatigue and vigor, as measured by the POMS, were not significantly different between groups. The lack of a significant difference in mean fatigue ratings between groups is consistent with some prior work using the POMS with older adults . In thatThe reasons for these inconsistent findings and the lack of group differences in POMS fatigue and vigor ratings in the current study are unclear. As mentioned above, differences in the target population, college-age adults who are successful in a highly competitive academic environment versus the general population, could play a role. It is also possible that the younger individuals in the current study had more experience adapting to their hearing loss and that their subjective perception of the impact of that hearing loss might be different than older adults or even younger children who have not yet learned to navigate their environment as an individual with a sensory deficit. However, the inconsistent findings may also reflect a weakness of generic fatigue measures for examining listening-related fatigue. This is supported by our finding that, when asked questions specifically targeting listening-related effort and fatigue , AHL reported they experienced significantly more listening effort and listening-related fatigue than their NH age-matched controls.In addition, using these listening-specific measures, we observed a significant correlation between subjective listening effort and listening-related fatigue. This finding is consistent with that of Additional measurable benefits from cochlear implantation, such as reduced listening effort and listening-related fatigue, should be considered when assessing successful outcomes in other areas of the recipient's everyday life. The audiologist's largest measure of CI success has been and continues to be speech-based measures. However, we often see that clinical speech measures do not translate well to real-world benefit, highlighting the need for additional relevant outcome measures.To be successful in an academically challenging, doctoral program, as were these study participants, requires an ability to cope with stress and adversity. As discussed above, the participants in this study were successful CI/HA users who had long-standing, successful experiences with their listening devices. It is possible that, by selecting this group as study participants, we have underestimated the potential impact of hearing loss on stress, effort, and listening-related fatigue.Finally, it would also be interesting to follow these individuals over time to see how their perceptions of vigor and fatigue change as a result of electrical stimulation. These changes could be a useful health-related quality of life outcome measure, which is currently not included in the battery of tests clinicians use to assess outcomes.This is the first study to examine the relationship between diurnal salivary cortisol levels, subjective ratings of listening effort, and fatigue in college-age adults with severe-to-profound hearing loss. AHL experienced more effortful listening during their day and, as a result, reported more listening-related fatigue than their age-matched controls without hearing loss. Consistent with the literature e.g., , we obsenonauditory effects of hearing loss, a questionnaire specifically designed to measure listening-related fatigue in individuals with hearing loss would be beneficial.Currently, listening effort and fatigue can be evaluated clinically using questionnaires. These questionnaires can be used to quantify the amount of effort or difficulty in listening but ultimately reveal one's perception of the ease or effort involved . Because


Background: To maximize the effect of intravenous (IV) thrombolysis and/or endovascular therapy (EVT) for acute ischemic stroke (AIS), stroke centers need to establish a parallel workflow on the basis of a code stroke (CS) protocol. At Kokura Memorial Hospital (KMH), we implemented a CS system in January 2014; however, the process of information sharing within the team has occasionally been burdensome.Objective: To solve this problem using information communication technology (ICT), we developed a novel application for smart devices, named “Task Calc. Stroke” (TCS), and aimed to investigate the impact of TCS on AIS care.Methods: TCS can visualize the real-time progress of crucial tasks for AIS on a dashboard by changing color indicators. From August 2015 to March 2017, we installed TCS at KMH and recommended its use during normal business hours (NBH). We compared the door-to-computed tomography time, the door-to-complete blood count (door-to-CBC) time, the door-to-needle for IV thrombolysis time, and the door-to-puncture for EVT time among three treatment groups, one using TCS (“TCS-based CS”), one not using TCS (“phone-based CS”), and one not based on CS (“non-CS”). A questionnaire survey regarding communication problems was conducted among the CS teams at 3 months after the implementation of TCS.Results: During the study period, 74 patients with AIS were transported to KMH within 4.5 h from onset during NBH, and 53 were treated using a CS approach . The door-to-CBC time was significantly reduced in the TCS-based CS group compared to the phone-based CS group, from 31 to 19 min (p = 0.043). Other processing times were also reduced, albeit not significantly. The rate of IV thrombosis was higher in the TCS-based CS group . The questionnaire was correctly filled in by 34/38 (89%) respondents, and 82% of the respondents felt a reduction in communication burden by using the TCS application.Conclusions: TCS is a novel approach that uses ICT to support information sharing in a parallel CS workflow in AIS care. It shortens the processing times of critical tasks and lessens the communication burden among team members. Early administration of intravenous tissue plasminogen activator (IV-tPA) and/or endovascular therapy (EVT) is associated with improved outcomes in acute ischemic stroke (AIS) , 2. GuidIn a stroke center, many tasks need to be performed across multiple departments in order to quickly decide on the therapeutic indication for IV-tPA or EVT , 4. The At Kokura Memorial Hospital (KMH), we have attempted to shorten DTN times since January 2014, by designating a professional team in the organizational structure and implementing a 24/7 CS system consisting of a pre-arrival notification and activation of the entire stroke team by phone, rapid laboratory testing, an uninterrupted supply of the IV-tPA tool kit, and continuous availability of computed tomography (CT) and magnetic resonance imaging (MRI). In 2014, the annual median DTN time was reduced from around 90 min in the previous year to about 40 min.However, new problems have appeared after the implementation of CS. When CS is initiated, various team members from several divisions of the hospital have to be contacted by phone. Communication delays occasionally occur when the emergency department (ED) is crowded and staff cannot call immediately, or when phone lines are busy. Moreover, during normal business hours (NBH), defined as the period of time in the hospital from 08:30 until 17:00 on the same day from Monday through Friday, various in-hospital procedures, such as laboratory testing, CT, MRI, and angiography, are booked out with pre-scheduled appointments. While the algorithm was running, team members had to coordinate by making many phone calls among themselves, which was sometimes perceived as a significant burden on the team. However, because the accurate arrival time of a patient at a test site is often unknown, tests are often delayed, resulting in extended DTN times.To solve these problems regarding the sharing of information by an organized CS team using information and communication technology (ICT), we developed “Task Calc. Stroke” (TCS), a visual management application for smart devices , and insTCS is an in-house application for smart devices or personal computers that is implemented via the internet. On August 1, 2015, using commercially available smart devices , TCS was installed in the emergency room (ER), CT scan room, MRI room, angiographic room, clinical laboratory room, stroke care unit, and conference room at KMH. These devices were used in a static manner and required personnel to remain at a specific place; hence, we used TCS only during NBH. The stroke specialists also accessed TCS from their own devices see .From August 2015 to March 2017, we recommended the use of TCS to ED doctors when CS was initiated for patients with suspected AIS who arrived at KMH within 4.5 h from onset during NBH.TCS enables parallel CS workflow by visualizing the progress of the multiple tasks involved in AIS care and sharing them among the medical staff. When TCS is not used, for realizing parallel workflow, medical staff need to make various phone calls or use instant messaging applications among the team. TCS visually supports four main functions as described in the following:Notifications: When the ED doctor receives an emergency pre-arrival notification, he/she can quickly notify all stroke team members of the arrival of a suspected stroke patient and of the estimated arrival time, with a single click on the device. Then, the TCS located in each department makes a loud sound and indicates that a patient is being transported.Color recognition: In line with the workflow of the CS that started in 2014 at KMH, critical tasks assigned to medical staff in each department  are displayed as colored hexagons in order of priority on the TCS dashboard , a group where CS was used without TCS (“phone-based CS”), and a group where the CS system and the TCS application were used (“TCS-based CS”). To investigate the effect of TCS on AIS care, we compared D2C times, door-to-complete blood count  times, DTN times for IV-tPA, and door-to-puncture times for EVT between the TCS-based CS and phone-based CS groups of patients transported during NBH. We also compared IV-tPA and EVT rates between the TCS-based CS and phone-based CS groups of patients transported during NBH.To investigate the effect of CS itself, we compared D2C times, door-to-CBC times, DTN times, and D2P times between the non-CS and phone-based CS or TCS-based CS groups.We conducted a questionnaire survey regarding communication problems in the workplace among the team at 3 months after the implementation of TCS.The ethics committee of KMH approved this study. Opt-out consent was obtained instead of written informed consent. We provided patients with information explaining the proposed research plan  via the website of KMH and gave them the opportunity to opt out at any point during the study. All procedures were in accordance with the Helsinki Declaration of 2000 and the Declaration of Istanbul of 2008.The study sample size was determined according to feasibility and to avoid overfitting. Since we planned to use four covariates in the primary analysis, at least 60 patients were required . A finalhttp://www.r-project.org). For the primary analysis, multiple linear regression models were used to assess independent associations between the treatment groups  during NBH and key task processing times  time for EVT) with adjustments for large vessel occlusion (LVO), oral anticoagulants, and the initial National Institutes of Health Stroke Scale (NIHSS) score as a confounder. For the secondary analysis, effects of the treatment  outside of NBH on key task processing times were also assessed using a multiple linear regression model adjusted for the abovementioned confounders. To assess the effects of TCS on IV-tPA and EVT for CS, a multivariable logistic regression model was used adjusted for LVO, oral anticoagulants, and the initial NIHSS score as a confounder. To assess the dispersion of key time metrics, the variance estimators and their confidence intervals (CIs) were used. Distributions of key time metrics were distorted to the left, and outcomes were thus natural log-transformed to ensure normality in regression residuals. An F-test was performed to compare the variance between the two groups. A p-value <0.05 was considered statistically significant for all analyses.Data are expressed as numbers and percentages, or as mean values ± standard deviations. Statistical analyses were performed using the statistical software SPSS version 11.0  and R version 3.5.1 . Other processing times were also reduced but not significantly. The rate of IV-tPA was higher in the TSC-based CS than in the phone-based CS group (78% vs. 46%) (p = 0.037) (p = 0.174) (The key task processing times are shown in vs. 46%) . A multi= 0.037) . The rat= 0.174) , 4.p < 0.001; β = 0.36, p < 0.001), the door-to-CBC time , and the DTN time . As for the patients treated outside of NBH, compared with the non-CS group, phone-based CS led to a statistically significant reduction in the following times: D2C time , door-to-CBC time , and D2P time  (The key task processing times are shown in = 0.029) .Regarding the questionnaire survey, there were 34/38 (89%) valid responses . In the phone-based CS group, problems such as the following were noted: repeated calling due to busy or unreachable phone lines; failing to notify other team members; redundant calling of the same department by mistake; calling a wrong phone number; and forgetting a phone number. In the TSC-based CS group, 82% (28/34) of respondents felt the communication burden to be reduced, compared to the phone-based CS group.In the present study, the use of TCS in the parallel CS workflow significantly reduced door-to-CBC times, increased the rate of patients with IV-tPA, and, at the same time, lessened the burden of information sharing among the team members.Several applications for AIS care have been developed earlier. These applications are excellent for image and text information sharing, but they do not have a multitask progress management function –18. UnliIn line with previous reports –10, thisThe rate of IV-tPA was higher in the TCS-based CS group than in the phone-based CS group. Likewise, the rate of EVT was almost 2-fold in the TCS group compared to the non-TCS group. The exact reason for this is unclear, but we assume that, together with the reduction in the door-to-CBC time, the cohesion of the CS team, as an effect of the TCS, influenced the choice of the more aggressive treatment protocols.In this study, we installed TCS in the ER, CT/MRI/angiography sites, laboratory, stroke care unit, and conference room and used it statically due to limited connection to the internet, thus requiring the personnel to remain at a specific location. Hence, improving internet access and availability could possibly further enhance the use of TCS 24/7.Real-time feedback of time metrics to the stroke team members is essential to improve the quality of acute stroke care . HoweverOur study has several limitations. First, the study design is retrospective in nature. It does not represent a continuous case series and has a relatively small sample size. Furthermore, selection bias and random errors may have affected the results. Second, the study was conducted at a single center. Third, that TCS was only used during NBH is a significant limitation of the study, because off-regular working hours and weekends are particularly limited in resources and personnel, and TCS would be of particular benefit during that period. Clinical trials that enable 24/7 use of TSC are thus required. Fourth, the statistical model for DTN times for IV-tPA showed slight overfitting. Therefore, the present results should be regarded as preliminary. Further prospective multicenter studies or clinical trials to confirm the 24/7 usefulness of TCS are recommended.In conclusion, we developed a visual task management ICT application that supports parallel CS workflow in AIS care. In the single-center study described here, we show that using TCS shortens the processing times of some critical tasks and reduces the burden of information sharing among team members. TCS is a novel approach that enables rapid and stable stroke care. We therefore recommend our system to be applied in the care of patients with acute stroke worldwide.All data sets generated for this study are included in the manuscript files.The studies involving human participants were reviewed and approved by The Ethics Committee of Kokura Memorial Hospital approved this study. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SM, HK, INak, and JKi conceived the design of the paper. INak, AI, THat, TO, MA, HC, WT, KTo, THashik, YF, TK, EH, SW, DK, AT, KF, THashim, JKo, KS, TT, HN, TI, RY, and INag contributed to the acquisition and analysis of the data. SM, HK, JKi, TO, KTa, and TI contributed to drafting the text and preparing the figures. All authors contributed to and approved the final manuscript.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.


The extended Cd 4d-orbitals lead to more itinerant characters of Li1+yP than that of analogous Li1+yP. A higher Curie temperature of 45 K than that for Li1+yP is obtained in Li1+yP polycrystalline samples by Arrott plot technique. The p-type carriers are determined by Hall effect measurements. The first principle calculations and X-ray diffraction measurements indicate that occupation of excess Li is at Cd sites rather than the interstitial site. Consequently holes are doped by excess Li substitution. More interestingly Li1+yP shows a very low coercive field (<100 Oe) and giant negative magnetoresistance (~80%) in ferromagnetic state that will benefit potential spintronics applications.We report a new diluted ferromagnetic semiconductor Li For the prototypical III-V diluted ferromagnetic semiconductors, such as As, substitution of divalent Mn2+ into trivalent Ga3+ results in coupled spin & charge doping, which makes individual control of spin and charge difficult4. Additionally, the heterovalent substitution of Mn2+ into Ga3+ also leads to severely limited chemical solubility, and results in the specimens only available as thin films and sensitive to preparation methods and annealing treatments6. The coupled spin and charge is an obstacle not only for fundamental understanding of ferromagnetic mechanism but also for effective improvement of controllable Curie temperature (TC).Diluted ferromagnetic semiconductors have received extensive attention because of their potential applications for spintronics devicese.g. “111” type LiAs and LiP, “122” type 2As2 and “1111” type SbO, have been discovered to overcome the aforementioned difficulties16. In these new types of diluted ferromagnetic semiconductors spin is doped via isovalent substitution of , while charge is provided by off-stoichiometry of Li in the “111” type diluted ferromagnetic semiconductors or by heterovalent substitution of cations in the “122” and “1111” diluted ferromagnetic semiconductors. With the advantage of independent spin and charge doping, a record of controllable TC of 230 K is achieved in 2As217. Furthermore, a number of progresses of these new generation diluted ferromagnetic semiconductors have been made on both fundamental studies and potential applications22. Large size single crystals and single-phase thin films of 2As2 have been grown25. Based on single crystal samples, a Mn-impurity band is identified by angle-resolved resonance photoemission spectroscopy, demonstrating strong hybridization between Mn 3d- and As 4p-orbitals26. The magnetic pair distribution function measurements discover presence of robust nearest-neighbor ferromagnetic alignment of Mn spins along the c axis even well above TC27. Andreev reflection junction is fabricated with single crystal 2As2. The obtained spin polarization rate of 66% is comparable to the prototypical diluted ferromagnetic semiconductors, suggesting large potentials of application in these new generation diluted ferromagnetic semiconductors30.Recently a series of new generation diluted ferromagnetic semiconductors, TC is always a fundamental issue for diluted ferromagnetic semiconductor materials. As well known, TC depends on the p-d exchange between carriers and Mn ions. Generally, greater p-d exchange can be reached by shortening bond length in Mn-ligand. However among the “111” diluted ferromagnetic semiconductor materials, LiP has lower hole concentration and lower TC than those of LiAs. Generally, ferromagnetism in a diluted magnetic semiconductor is mediated by itinerated carriers. Thus a higher TC is expected with further carrier doping in LiP. However, further improvement of carrier concentration by changing the Li concentration is invalid in LiP. To overcome the difficulty we make a new diluted ferromagnetic semiconductor compound LiP, where the extended Cd 4d-orbitals lead to more itinerant characters of LiP than that of analogous LiP. LiP is expected to have larger hole concentration and consequently higher TC than LiP. In this article we report the synthesis and characterizations of the Cd-based diluted ferromagnetic semiconductor, LiP.Improvement of 1.1(Cd1−xMnx)P . Parent phase LiCdP and doped samples Li(CdMn)P crystallize into a zinc-blende like structure with the space group of F-43m, as shown in the inset of Fig. a = 6.089(2) Å for parent phase LiCdP is consistent with the previous report31 and larger than LiZnAs (a = 5.940(2) Å) and LiZnP (a = 5.756(1) Å).Figure 1.1Cd0.9Mn0.1P. The results don’t show any trace of defect or cluster P are shown in Fig. 2+ (0.66 Å) than that of Cd2+ (0.78 Å)32. The decrease of lattice parameter with increasing Li concentration will be discussed later.Homogeneity and real atomic ratios are studied with energy dispersive analysis (EDX). Except the light element Li, the atomic ratios of Cd, Mn and P are measured. The results show that all the detected elements are well distributed and their ratios are consistent with the nominal compositions )for Li1.1(Cd1−xMnx)P present upturns on lowering temperature, clear signatures of ferromagnetic transition, as shown in Fig. 3O4 has a comparable TC = 42 K. In contrary, TC of LiP compounds changes from 15 K to 45 K according to their composition, ruling out the possibility of Mn3O4. The hysteresis curve (M(H))of Li1.1(Cd0.925Mn0.075)P at T = 6 K is plotted in Fig. 9. Because Mn cations are randomly distributed in material, some Mn cations which locate far away from each other cannot be mediated by carries to form long range ferromagnetic order and consequently lead to local paramagnetic spins. The inset of Fig. HC < 100 Oe) that is promising for spin manipulation. After subtracting the linear field-dependent component, the magnetic hysteresis loops of Li1.1(Cd1−xMnx)P  specimens at 6 K are shown in Fig. M6K,1T) is used to approximately represent saturation magnetizations in following discussions. The M6K,1T = 0.94, 0.83, 0.69, 0.62 μB/Mn for samples of x = 0.025, 0.05, 0.075 and 0.10 respectively. They are smaller than that of As4 and LiAs7 possibly due to the competition between the long range ferromagnetic ordering and the short range antiferromagtic interactions. The tendency that the M6K,1T reduces with increasing Mn doping levels has also been found in many magnetic ions doped materials33. One rational reason is the competition between ferromagnetic interaction of Mn mediated by carriers and antiferromagnetic coupling of Mn pairs in the nearest neighbor sites, as discussed in “111” and “122” diluted ferromagnetic semiconductors12.Parent phase LiCdP is diamagnetic. Single excess Li- and Mn-doping just makes the compound Pauli paramagnetic and paramagnetic P. The TC for the other samples are obtained in similar way. Table TC and M6K,1T for various compositions of Li1+y(Cd1−xMnx)P. When Mn concentration is fixed, one can note that excess Li initially improves both TC and M6K,1T within low Li concentration but then suppresses ferromagnetic order when y = 0.2. On the other hand, except samples with overdoped Li (y = 0.2), increasing Mn enhances the TC but declines the average local moments on Mn .In the paramagnetic region, the susceptibility can be well fitted by the Curie-Weiss law, as shown in Fig. ρ(T)) for a series of Li1+yCdP . Consistent with ref.31, the parent compound LiCdP present semiconducting conduction31. Excess Li doping decrease resistivity, suggesting the effective doping of carriers. Figure 1.1(Cd1−xMnx)P increases with increasing Mn concentration, caused by localization effect. Although carriers introduced by excess Li doping are originally itinerant, they will be weakly bound to the Mn local spin moments and then partially lose their mobility34. The similar conducting behavior has been observed in 2As2. The localization of the carriers has been confirmed by Mn K β x-ray emission spectroscopy measurements which indicates that Mn local spin moments traps holes and in turn is declined by hole doping20.Figure 1.1(Cd0.9Mn0.1)P specimen as a typical example. The value of negative MR (about −80%) is at least twice larger than those of analogues LiAs and LiP8. The negative MR may result from reduction of spin-dependent scattering by aligning the spins under applied field. The Hall effect measurements of all the samples show p-type carriers. Hole concentration (np) of the parent phase is ~1017 cm−3 at 200 K. More holes are doped by excess Li substitution in Li1.1CdP which has np = 3.8 × 1019 cm−3 at 200 K. In ferromagnetic sample Li1.1(Cd0.95Mn0.05)P, 5% Mn doping slightly decreases to np = 2.7 × 1019 cm−3 at 200 K. At lower temperature the resistivity was too large, any small misalignment of the two Hall contacts picks up a longitudinal resistivity signal and this leads to great difficulty in the Hall effect measurement 35. From LiP to LiP, the hole concentration is considerably increased, and consequently the TC is improved from 34 K to 45 K. As the Zener model predicted, the ferromagnetism is mediated by carriers, and the Curie temperature is positive correlated with hole concentration.A giant negative magnetoresistance (MR) is observed in all of the ferromagnetic Li(CdMn)P samples. Figure In order to have insight into the origin of hole carrier, we performed calculation on electronic structures with density functional theory (DFT). Calculation shows that the band structure of LiCdP is very similar to that of LiZnP. The band structure of parent phase LiCdP is shown in Fig. I and (ii) the Cd-substitutional site LiCd. The former can provide n-type carrier and the latter will serve as a hole donor. We calculate the formation energy for the two excess Li-sites, respectively. Since Mn at Cd-substitutional site MnCd does not introduce any carriers, we study the excess Li in Li1+yCdP for simplification. According to previous work36, the formation energy is given by Eformation = ET − nLiμLi − nCdμCd − nPμP, where ET is the total energy of the supercell, nx is the number of x atoms in the supercell, and μx is the atomic chemical potential. It has μLi + μCd + μP = μLiCdP(bulk). Table i.e., the Li-rich plus Cd-rich limit (μLi = μLi(bulk), μCd = μCd(bulk)) and the Li-rich plus P-rich limit (μLi = μLi(bulk), μP = μP). Under both conditions, compounds with LiCd have lower formation energy. The experimental condition must be between these two extreme conditions. It recalls the reduction of lattice parameter with excess Li doping found in XRD measurements. The excess Li at interstitial site is supposed to stretch the lattice. In contrary, substitution of Li into Cd should shrink the lattice due to the smaller Li+ radius (0.59 Å) than Cd2+ (0.78 Å)32. Thus we argue that in LiP the excess Li atoms prefer to occupy Cd-substitutional sites LiCd, and thus create the p-type carriers.Two possible different sites for excess Li are discussed in the calculations, (i) the interstitial site Lip-d exchange and more importantly a Curie temperature of 45 K which is one third higher than TC of LiP. In addition, the observed properties in LiP, such as the low coercive field and the giant negative magnetoresistance, are favorable for future applications. In short, the successful prediction and fabrication of LiP open an new boulevard to tailor the ferromagnetism in diluted magnetic semiconductors.In this work, “111” type Cd-based LiP has been designed to achieve high Curie temperature. In LiP replacement of Zn by Cd successfully compensates for the high hole binding energy in the LiP by increasing Mn-P bond length. As a result, LiP has enlarged the hole concentration, amplified the effective Kα radiation. Real compositions of the heavy elements  were determined by using energy dispersive analysis (EDX) on a commercial Scanning Electron Microscope (SEM). Microstructure was studied by high resolution Transmission Electron Microscope (TEM). The dc magnetic properties were examined by using Superconductivity Quantum Interference Device , and transport properties were examined by Physical Property Measurement System . We calculated the electronic structures by using the density functional theory (DFT) implemented in the code QUANTUM ESPRESSO36. The exchange-correlation interactions are described by the Perdew-Burke-Ernzerhof generalized gradients approximation (GGA), and the electronion interactions are represented by the Vanderbilt ultrasoft pseudopotentials.Polycrystalline specimens of LiP were prepared by solid state reaction with high purity elements. The stoichiometric ratios of starting materials were well mixed and pressed into pellets. All the processes were performed under the protection of high-purity Argon due to the air sensitivity of precursors and products. The pellets were sealed in Ta tubes under 0.5 bar of Argon before being sealed into evacuated quartz tubes. The samples were heated at 470 °C for 48 h. Then the products were reground and sintered at 680 °C for 48 h, followed by a quick quenching to room temperature. The recovered samples were characterized by X-ray powder diffraction (XRD) with a Philips X’pert diffractometer using CuThe Supporting Materials


Lawsonia intracellularis (L. intracellularis) is the etiologic agent of porcine proliferative enteropathy (PPE), which is reported in many swine breeding countries all over the world, and has caused enormous economic losses in intensive pig production systems. Therefore, the aim of this study was to develop a simple and rapid method for on-site detection of Lawsonia intracellularis (L. intracellularis). As the isothermal recombinase polymerase amplification (RPA) can be performed at a constant temperature and its product is directly observed on a lateral-flow dipstick (LFD) with naked eyes without electrophoresis, the RPA-LFD assay should be useful for field diagnosis of L. intracellularis as well as its detection from clinical samples.L. intracellularis, and did not detect nucleic acids extracted from other common gastrointestinal pathogens. The minimum detection of this RPA-LFD method was 400 L. intracellularis per reaction, which was as sensitive as conventional PCR. Further, the RPA-LFD assay was performed with 150 clinical fecal samples and the detection results were compared with conventional PCR. Results showed that the coincidence rate of RPA-LFD and conventional PCR was 100%.The established RPA-LFD assay could be finished in 30 min at a wide temperature range of 25 to 40 °C, and the amplicons could be visualized by naked eyes. The developed RPA-LFD assay was specific to dnaA gene of L. intracellularis infection.The combined RPA with LFD assay provides a simple, rapid, specific and sensitive alternative for field diagnosis of  Lawsonia intracellularis, a fastidious and obligate intracellular bacterium, belongs to the bacterial genus Lawsonia and is the etiologic agent of porcine proliferative enteropathy (PPE), which is characterized clinically by mild to severe diarrhea, retarded growth and/or sudden death in fattening pigs and macroscopically by thickening of the intestinal mucosa due to enterocyte proliferation [L. intracellularis infection was reported in 1931 [L. intracellularis was first isolated from the intestinal mucosa of infected pigs in Southern China in 2008 [L. intracellularis in Chinese pig herds was 77%, evaluated by a blocking ELISA in 2014. A higher seroprevalence was found in fattening pigs, sows and boars compared with pre-weaning piglets and weaners [L. intracellularis effectively, simple, rapid, sensitive and accurate methods suitable for field detection of L. intracellularis are critical.feration , 2. Sinc in 1931 –9. In Ch in 2008 . The ove weaners . To contL. intracellularis is based on the demonstration of the microbe or microbial DNA in tissue specimens or fecal samples, or the demonstration of L. intracellularis-specific antibodies in sera. Current available diagnostic methods for L. intracellularis infection in live animals include serological tests for detecting antibody against L. intracellularis, such as enzyme-linked immunosorbent assay (ELISA) [L. intracellularis in fecal samples, such as polymerase chain reaction (PCR)-based tests [L. intracellularis requires establishment of suitable cell lines and L. intracellularis cannot be cultured in conventional cell-free medium. Although PCR-based molecular diagnostic tools are sensitive and capable of detecting L. intracellularis from various clinical samples, these techniques are restricted to the laboratory due to the requirements for sophisticated equipment, complex experimental procedures, skilled personnel and subsequent analysis. PPE may also be diagnosed postmortem from the typical macroscopic lesions, but histological confirmation by immunohistochemistry (IHC) test is needed [L. intracellularis infection does not show specific clinical signs of illness at the earlier stage of infection, which often leads to the missing diagnosis. Hence there is an urgent need for a rapid and reliable pen side diagnostic assay for a better detection and control of this economically important disease of swine.The diagnosis of  (ELISA) –14, immu (ELISA) , indirec (ELISA) , and meted tests –24 and Ied tests . Among ts needed –28. SincRecombinase polymerase amplification (RPA) is a novel isothermal amplification technology which couples isothermal recombinase-driven primer targeting of template material with strand-displacement DNA synthesis . It overL. intracellularis DNA in fecal samples for the first time. The specificity and sensitivity of the RPA-LFD were evaluated. And the effectiveness of the RPA-LFD was determined by detecting clinical fecal samples.In this study, RPA coupled with LFD system (RPA-LFD) was developed to detect http://www.ncbi.nlm.nih.gov/blast/Blast.cgi). As expected, the primer combination was 100% identical to sequences of dnaA gene of L. intracellularis from pigs (GenBank accession nos. CP004029 and AM180252). The RPA basic reaction was performed by using unlabeled primers at 37 °C for 25 min to test the usability of the primers. The result of amplification showed that the 292-bp target gene could be successfully amplified. The sequencing results of RPA products were in good agreement with the dnaA gene of L. intracellularis. However, the target gene could not be amplified from DNA sample negative for L. intracellularis and a non-template control  and a negative control  were included to ensure the test would not report a false positive. As shown in Fig. L. intracellularis-specific RPA-LFD could efficiently detect the L. intracellularis in clinical feces, and the detection results were in 100% coincidence with those of conventional PCR.The clinical performance of the L. intracellularis is one of the most economically important pathogens in the swine production. It causes chronic diarrhea and poor performance in young growing pigs. Simple, rapid, sensitive and accurate methods suitable for field detection of L. intracellularis are crucial to efficiently control the infection and the spread of the L. intracellularis in time. Diagnosis of L. intracellularis is usually based on the demonstration of the microbe or microbial DNA in tissue specimens or fecal samples by PCR-based methods, or the detection of L. intracellularis-specific antibodies in sera by serological assays. However, the current diagnostic methods have several unneglectable limitations, such as antigen availability, the need of trained personnel to conduct the diagnostics, handling of the complex equipment, shipment and storage of samples to a distant laboratory. RPA is relatively new isothermal amplification method with the support of recombinase, a strand-displacement polymerase and a single-strand binding protein. The RPA does not need special instruments and can amplify target DNA to detectable level in less time and at lower temperature than those of other DNA amplification techniques. A lateral flow dipstick (LFD) is a visual testing tool that eliminates the need for trained personnel and expensive equipments. Therefore, the platform composed by RPA and LFD shows multiple advantages, such as convenient operation, rapid reaction, easy visualization of result and less equipments and skilled personnel requirement, which make it ideal for field diagnosis of L. intracellularis infection.L. intracellularis is an obligate intracellular bacterium that is difficult to culture, and its detection and quantification pose a challenge for epidemiological and infection studies [L. intracellularis for the first time. Two labelled primers targeting the dnaA gene of L. intracellularis were designed. The RPA reaction generated a dual-tagged DNA amplicon which could be visualized on the LFD with naked eyes by untrained personnel. This is especially important for areas where instruments and trained veterinary workers are deficient. Regarding the specificity of this RPA-LFD method, there was no cross-reaction with other usual porcine gastrointestinal bacteria and viruses. The sensitivity of the RPA-LFD was evaluated and compared with conventional PCR by using pure-cultured number-determined L intracellularis in this study. Since there is currently no gold standard method for the detection of L. intracellularis, and L. intracellularis cannot be cultured on artificial bacteriological media, it is hard to document accurately the specificity and sensitivity of the RPA test without samples confirmed by a gold standard test or bacteria isolation and identification. However the RPA-LFD could discriminate L.intracellularis from other common porcine gastrointestinal pathogens. Based on this result, the specificity of the RPA-LFD is 100%, even only one known L.intracellularis positive sample was included. Our results showed that the established RPA-LFD had a same detection threshold of 400 L. intracellularis per reaction for both pure-cultured L. intracellularis and feces sample spiked with pure-cultured L. intracellularis. Moreover, the RPA-LFD was found as sensitive as the conventional PCR. We believe that samples containing more than 400 L. intracellularis can be 100% detected by the RPA-LFD. To mimic the field detecting condition and to test whether fecal-PCR inhibitors were affecting RPA amplification and LFD detection, we also evaluated the sensitivity of the RPA-LFD by using DNA extracted from feces sample spiked with pure-cultured number-determined L. intracellularis as templates for RPA-LFD and conventional PCR. The detection limit of the RPA-LFD turned out to be 400 L. intracellularis per reaction in both cases. However, the specific bands amplified in conventional PCR from spiked feces samples were fainter than that of amplified from samples containing same number pure-cultured L. intracellularis  assay after inoculating L. intracellularis-free pigs with 5 × 105 bacteria per pig [L. intracellularis in feces sample presented in this study provided a means to monitor L.intracellularis shedding from naturally or experimentally infected pigs. Given the sensitivity of RPA-LFD was comparable to that of conventional PCR in detecting clinical feces samples, the RPA-LFD still had several advantages over the conventional PCR, such as more convenient operation, more rapid reaction, less equipment requirement and the results could be visualized by naked eyes. studies . In thisris Fig. B. The ab per pig . Thus, tL. intracellularis RPA-LFD included the elimination of the requirement of designing a special labelled probe, the shorter incubation time and lower single incubation temperature. Our study showed that the RPA-LFD assay could efficiently detect L. intracellularis from clinical fecal samples using two labelled primers rather than two primers and one probe in conventional RPA. The RPA-LFD assay could amplify target DNA at a relatively low, constant temperature from 25 to 42 °C, whereas the optimum reaction temperature was 30 to 42 °C. This means that a simple heating device, such as water bath or even body heat, can be used to achieve amplification and detection. The RPA-LFD assay could amplify the target DNA to detectable levels within 5 to 10 min, which was much shorter than those of conventional PCR-based methods. Currently, most of the reported RPA assays were developed by using commercial RPA kit from the TwistDx Company. The products of commercially available TwistAmp™ nfo kit can be detected by the LFD. However compatible probe is needed for the TwistAmp™ nfo kit. A TwistAmp™ LF probe consist of an oligonucleotide homologous to the target sequence which incorporates a 5’ -antigenic label, an internal abasic nucleotide analogue (a tetrahydrofuran residue or THF) which replaces a conventional base found in the target, and a polymerase extension blocking group  at the 3’ end, and the probe is typically 46–52 nucleotides long, at least 30 of which are placed 5’ to the THF site, and at least a further 15 are located 3’ to it [L. intracellularis [L. intracellularis RPA-LFD was faster than RT-LAMP (15 min in L. intracellularis RPA compared to 30–60 min in RT-LAMP). Moreover, RPA-LFD in this study only required a single pair of primers, while RT-LAMP needed at least 6 primers.The additional advantages of the 3’ to it . Though llularis . HoweverL. intracellularis RPA-LFD assay was evaluated with 150 clinical fecal samples and compared it with PCR. The reason we chose fecal samples is that L. intracellularis was always shed from feces of sick swine and the feces were easily acquired and non-invasive. As the sensitivity of RPA-LFD was comparable to that of conventional PCR in detecting clinical feces samples, the RPA-LFD results were in 100% coincidence with those of conventional PCR. Even though the conventional PCR is also suitable to detect L. intracellularis, the RPA-LFD still have multiple unique advantages as stated above.The diagnostic validation of the L. intracellularis on-site detecting possible.In this study, the RPA templates could be prepared from clinical fecal samples with magnetic bead-based extraction methods. Compared with the traditional nucleic acid preparation methods, extraction using magnetic beads is easy and time saving, and does not require potentially dangerous procedures or specialized laboratory equipments . The whoL. intracellularis RPA-LFD demonstrated multiple advantages, such as high sensitivity, good specificity, convenient operation, rapid reaction and less equipment requirement, which was suitable not only for pen side diagnosis but also for field screening and monitoring of the L. intracellularis infection. This technique can be used for epidemiological surveillance activities for L. intracellularis.In summary, the established L. intracellularis PHE/MN1–00 strain (GenBank accession no. AM180252), a pair of specific primers targeting the dnaA (ATPase involved in DNA replication initiation) gene was designed for RPA: 5′- AAATCCAAAAGTCGAGTATCTAACTGCGG-3′; reverse primer: 5′- TAAAAACCCAGAGCAAAATCGTGATACCAGGCG-3′. The size of amplicon is 292 bp. In order to detect the RPA products by the LFD assay, the forward and reverse primers were labelled at the 5′-end with Fluorescein isothiocyanate (FITC) and Biotin, respectively.Based on the published genome sequence of L. intracellularis  and Escherichia coli (E. coli), Salmonella Cholerasuis (S. Cholerasuis), Enterococcus faecalis , Brachyspira hyodysenteriae (B. hyodysenteriae) (ATCC-27164), porcine circovirus serotype 2 (PCV2), pseudorabies virus (PRV) Bartha-K61 strain, porcine rotavirus (PoRV), porcine epidemic diarrhea virus (PEDV) CV777 strain, transmissible gastroenteritis virus (TGEV) PUR46-MAD strain, classical swine fever virus (CSFV) vaccine C strain, samples containing the above pathogens except for L. intracellularis and samples containing all the above pathogens by using the genesig® DNA/RNA Extraction Kit  according to the manufacturer’s instructions. Briefly, 200 μl of sample were mixed well with 200 μl of lysis buffer and 20 μl of Proteinase K solution in a microcentrifuge tube. Then 500 μl magnetic beads/binding buffer were added to the lysed sample, mixed well and then separated by using a magnetic separator. The separated beads were washed by using Wash Buffer 1 and 2 and 80% ethanol, respectively. Add 50 μl Elution Buffer to the tube and resuspend the beads completely by repeated pipetting up and down. Then separate the magnetic beads from the sample and transfer the supernatant containing the purified DNA/RNA to a new tube and used for RPA. The protocol for extracting total DNA/RNA from clinical fecal samples is as follows: add 500 μl of Sample Prep Solution to approximately 10–20 mg of feces (a match head in size) or 200 μl if using liquid feces, and mix vigorously by shaking for 1 min. Allow the particles to settle down. Use up to 200 μl supernatant for the above extraction protocol.Genomic DNA/RNA was extracted from 2O, 2 μl of each primer (10 μM) and 2 μl template. To initiate the reaction 2.5 μl of magnesium acetate (280 mM) was added. Vortex and flip the reaction tube by hand or spin the reaction tube in a palm centrifuge. Reactions were performed at 37 °C in a water bath for 25 min. The amplification products were purified with QIAquick PCR Purification Kit  and analyzed on 2% agarose gel electrophoresis. For each experiment, a L. intracellularis negative  and a blank control were included.RPA basic reaction was performed to test the usability of the primers with the TwistAmp Basic kit  according to the manufacturer’s instruction. Briefly, the RPA reaction with a final reaction volume of 50 μl comprised of 29.5 μl rehydration buffer, 12 μl ddHFor lateral flow dipstick detection of the RPA products, the forward and reverse primers for RPA were labelled at the 5′-end with FITC and Biotin, respectively. Different concentration of primers, reaction duration ranging from 5 min to 30 min, and reaction temperatures ranging from 37 °C to 42 °C were evaluated to optimize the condition for the RPA-LFD assay. After amplification, the RPA products were detected by lateral flow strip  according to the instruction of manufacturer. The lateral flow strip contains streptavidin-coated colloidal gold on the sample pad, anti-FITC antibody on the Test line and biotin on the Control line. The result was considered valid if a pink line at the Control line was visible. The result was considered to be positive when the both Control line and pink Test line appeared.7, 106, 105, 104, and 103 bacteria) L. intracellularis attenuated vaccine strain B3903 . To mimic the field detecting condition, the sensitivity of the RPA-LFD was also evaluated and compared with that of the conventional PCR by using genomic DNA extracted from feces sample spiked with pure-cultured and number-determined L. intracellularis . The extracted DNA was dissolved in 50 μl Elution buffer, and 2 μl of extracted genomic DNA was used as templates for RPA-LFD and conventional PCR, respectively. Then the number of L. intracellularis per reaction was calculated as follow: bacterium number (107–103) / 50 μl × 2 μl, i.e. 4 × 105–4 × 101 bacteria per reaction. The PCR assay was performed in a 50 μl reaction containing 25 μl of 2 × Es Taq MasterMix , 2 μl of each primer (10 μM), 2 μl of template, 20 μl of ddH2O. The cycling parameters were 95 °C for 5 min, followed by 30 cycles of denaturation at 95 °C for 30s, annealing at 56 °C for 30s, extension at 72 °C for 20s, and a final extension of 72 °C for 10 min. The PCR was performed on a Bio-Rad T100 Thermal Cycler . After amplification, the PCR products were analyzed using agarose gel electrophoresis; and the RPA products were detected by the LFD.Based on the optimized conditions for RPA-LFD, the sensitivity of the RPA-LFD was evaluated and compared with that of the conventional PCR by using genomic DNA extracted from pure-cultured and number-determined  and a negative control  were included to ensure the test would not report a false positive.Clinical fecal samples from growing pigs suffering from diarrhea and poor performance were used to evaluate the diagnostic validity. For each experiment, a


Occupational therapy and occupational science are founded on the theoretical core assumption that occupation and quality of life (QoL) are closely related. However, such theoretical core assumptions must be supported through empirically based research.  To investigate the association between QoL and occupation, here self-reported and observed ADL abilities as a part of occupation, among people with advanced cancer, including determining whether self-reported or observed ADL ability had the stronger association with QoL.  The study was nested in a cross-sectional study. The association between ADL ability and QoL among 108 people with advanced cancer was investigated using the ADL Interview (ADL-I), the Assessment of Motor and Process Skills (AMPS), and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-C30).  Results showed that high observed ADL motor ability was associated with high QoL. In contrast, observed ADL process ability and self-reported ADL ability were not significantly associated with QoL. Oppositely expected, observed ADL ability had a stronger association with QoL than self-reported ADL ability. Thereby, the study to some extent contributes knowledge confirming the theoretical core assumptions about the relation between occupation, here performance of ADL, and QoL. Occupational therapy (OT) and occupational science (OS) are founded on the theoretical core assumption that occupation and quality of life (QoL) are closely related –4. OccupLikewise, the concept of QoL is understood as individually determined and influenced by the context in which the person lives . There an = 163) showed that 43% had difficulties with PADL and 74% regarding IADL [Within the framework of evidence-based practice, it is essential that the theoretical core assumption about a relationship between occupation and QoL is supported by empirically based research , 9. Studing IADL . Furthering IADL –23.n = 158) (29% were cancer patients), that both ADL ability and depressed mood were associated with QoL. This conclusion is supported by Yokoo et al. who, in an internet-based questionnaire, found in persons with cancer (n = 807) that “concerns about daily living” were one of many factors significantly associated with QoL [n = 533). Based on interviews, they concluded that “functional status,” defined as the ability to perform basic activities important to maintain independence, was one predictor of QoL [Interestingly, Solomon et al.  reportedwith QoL . This isr of QoL . Thus, bHowever, when evaluating ADL ability, studies recommend applying a combination of self-reporting and observation, as the two methods seem to provide complimentary information about ADL ability –29. TherThe aim of this study was, therefore, to investigate the association between QoL and occupation, here self-reported and observed ADL abilities, as a part of occupation among people with advanced cancer, including determining whether self-reported or observed ADL ability had the stronger association with QoL.P ≤ 0.05), (b) observed ADL ability would be statistically significantly associated with QoL (P ≤ 0.05), and (c) self-reported ADL ability would have a stronger association with QoL than observed ADL ability in people with advanced cancer (P ≤ 0.05).The hypotheses were according to the theoretical core assumptions that (a) self-reported ADL ability would be statistically significantly associated with QoL  , 32. ParData from 164 participants were contained in the study database. The most common types of cancer among the participants were cancer in the lungs, colon/rectum, breast, and prostate. For the present study, only participants with complete data according to the variables in the study were included. Thus, 39 participants with incomplete data sets were removed, due to missing WHO performance status, ADL, and/or QoL data, leaving a total number of 125 participants.The data collection in the cross-sectional study included a combination of study-specific and standardized questionnaires: standardized semistructured interviews and standardized observations. The participants received the questionnaires by mail. These were followed up by a home visit within one week. Four trained data collection occupational therapists (D-OTs) conducted the home visits and the data collection including performing the interviews and the observations according to a data collection manual.The questionnaires were twofold. The first part was a basic information questionnaire with 11 items regarding sociodemographic information, such as gender, age, and living alone/living in cohabitation. The second part was the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30). The instruments applied during the home visits included the ADL Interview (ADL-I) and the Assessment of Motor and Process Skills (AMPS).The EORTC-QLQ-C30 (v. 3.0) , 34 is aThe ADL Interview (ADL-I) , 39 is aCategorical data from the ADL-I are converted into an overall linear measure of each person's self-reported quality of ADL task performance presented in logits (log-odds probability units) based on Rasch measurement methods , 39. A hThe Assessment of Motor and Process Skills (AMPS) , 42 is aThe project was registered and approved by the Danish Data Protection Agency (J.nr. 2012-41-1404). According to the Regional Committees on Health Research Ethics for Southern Denmark, the ACQ project was not notifiable (Project ID S-20122000-96-CKH/csf). The principles of the Helsinki Declaration were followed . TherebyThe statistical analyses were performed using the statistical software package, the Stata software (v.14.1) by the StataCorp . The catAs the outcome variable, EORTC QoL, was rated on an ordinal scale, nonparametric statistics based on ordered logistic regression analysis were used to investigate ADL ability as a predictor of QoL , 49. HowThe ADL-I overall linear measure of self-reported quality of ADL task performance, the overall linear AMPS ADL motor ability measures, and the overall linear AMPS ADL process ability measures were chosen as exposure variables. All three exposure variables where each categorized into three subgroups . Since tThe criteria for categorization of the AMPS ADL motor and ADL process ability measures, respectively, were based on the independence cut-offs, predicting a need for assistance , 50, 51.To address the first aim in the study, a crude model of ordered logistic regression analysis , 49 was Demographic data including gender, age, and living alone or in cohabitation were selected to control for confounding in an adjusted model of the ordered logistic regression analysis , 49. ThiP value at <0.05 [The estimates in the ordered logistic regression analyses were presented based on the odds ratios (ORs) with 95% confidence intervals (CI) and a statistical significant at <0.05 , 49. Theat <0.05 . Finallyz-test for a difference in two odds ratios was applied to investigate a statistically significant difference among the three exposure variables on EORTC QoL [z-test, for the difference between the ORs for AMPS motor middle ADL ability as well as for AMPS process middle ADL ability, respectively. Likewise, the OR for high ADL-I ability were tested for the difference between the ORs for AMPS motor high ADL ability as well as for AMPS process high ADL ability, respectively. The estimates were presented based on the corresponding P values according to the z-scores, with a statistical significance at P < 0.05 [In order to address the second and last aim of the study, to test whether self-reported ADL ability would have a stronger association with QoL than observed ADL ability, a ORTC QoL , 49. FirP < 0.05 .n = 62), PS 2 (n = 43), and PS 3 (n = 3). The remaining descriptive characteristics and ADL ability measures are presented in Due to the low number of participants in the first, second, and seventh categories of the EORTC, additionally, 17 participants were excluded, leaving in total 108 participants for the analyses. The participants were distributed in WHO performance status (PS) categories 1-3: PS 1 (P = 0.02) and AMPS ADL process (P = 0.03) abilities were significantly associated with a higher-category QoL  (P = 0.04). For the AMPS ADL process, the adjustment for gender resulted in a borderline significant association with QoL in the group with high ADL ability (P = 0.053).In the ordered logistic regression analysis for each of the potential confounders, only the estimate for gender was significant ( = 0.02)  and ther = 0.02) , the resResults related to the second aim, testing whether self-reported ADL ability would have a stronger association with QoL than observed ADL ability, are shown in The overall purpose of this study was to investigate the association between QoL and occupation, here self-reported and observed ADL abilities as part of occupation, among people with advanced cancer, including determining whether self-reported ADL ability would have a stronger association with QoL than observed ADL ability.The study results confirm the hypothesis of an association between observed ADL ability and QoL, in a subgroup of participants with high ADL motor ability. In contrast, observed ADL process ability and self-reported ADL ability were not significantly associated with QoL. Thus, the study results to some extent support the theoretical core assumption of OT and OS and a relationship between occupation, here ADL, and QoL –4. TownsFrom an OS perspective, Yerxa described the close relationship between occupation and QoL , 4, inclThat ADL ability was associated with QoL among people with advanced cancer was partly in line with previous studies –26. As mAnother reason for differences between study results could be the instruments used to assess QoL. In the present study, the single item from the EORTC-QLQ-C30 was chosen. A similar approach was used in the study involving elderly persons with advanced illness  by posinAnother essential finding was the rejection of the third hypothesis regarding self-reported ADL ability having the stronger association with QoL. These results are in contrast to findings in the study by Amris et al. , who fouOne strength of this study is that the recruitment of participants was carried out using explicit inclusion criteria . FurtherMoreover, in this study, one of the two items from the combined scale addressing global health and overall QoL in the EORTC-QLQ-C30 was chosen: “How would you rate your overall quality of life during the past week?” The reason for using a single item from an established scale was to ensure the evaluation of the participants' perceived overall QoL without simultaneously influence from their perceived global health. Though this may be considered a potential limitation to the study results, this choice is well-founded. QoL is a complex concept to assess, as many aspects of life, including health status, may influence a person's perceived QoL. While the application of the combined scale of the global health and QoL in the EORTC-QLQ-C30 questionnaire might have provided more information about QoL, it would still not embrace all potential elements to a comprehensive study of a person's QoL. For example, as mentioned earlier, the understanding of QoL from an OT perspective by Townsend and Polatajko includes elements like choosing and participating in occupations that foster hope and generate motivation . In the The study showed a statistically significant association between observed ADL motor ability and high QoL. However, observed ADL process ability and self-reported ADL ability were not significantly associated with QoL, even though there was a tendency towards those participants with a high self-reported and/or observed ADL ability also reporting a better QoL. Therefore, the sample size may be considered a limitation, since the lack of a statistical significance may be explained by a small number of participants within each of the response categories of the EORTC-QLQ-C30. Furthermore, the sample did not represent the full spectrum of the EORTC QoL scale, and consequently, the interpretation of the results must be with some caution.When preparing AMPS and ADL-I data for data analysis, the AMPS motor and process ability measures were categorized based on established independence cut-offs. A similar approach was not possible, when handling the ADL-I measures, as cut-offs for interpretation of the ADL-I measures have not yet been established. This may be considered a study limitation, since there is a risk that the results could have been different, if other cut-points had been set. Still, the risk was considered minor, as the way to create the three ADL-I subgroups was plausible and acknowledged in the literature , 50, 51.Based on the study findings, it may be relevant for clinicians to suggest occupation-focused or occupation-based interventions as part of the palliative rehabilitation services, when working with people with severe diseases, like advanced cancer . A relevIn conclusion, this study found that observed high ADL motor ability had a statistically significant association with high QoL among people with advanced cancer. In contrast, observed ADL process ability and self-reported ADL ability were not significantly associated with QoL. Furthermore, the study found self-reported ADL ability not having a stronger association with QoL than observed ADL ability. Thus, despite the potential limitations, the study added a piece of knowledge to the evidence confirming the theoretical core assumptions regarding a close relationship between occupation and QoL, as understood in OT and OS –4. Howev