T+ Itpr3tf/J (BTBR) mice are used as a model of autism spectrum disorder (ASD), displaying similar behavioral and physiological deficits observed in patients with ASD. Our recent study found that implementation of an enriched environment (EE) in BTBR mice improved metabolic and behavioral outcomes. Brain-derived neurotrophic factor (Bdnf) and its receptor tropomyosin kinase receptor B (Ntrk2) were upregulated in the hypothalamus, hippocampus, and amygdala by implementing EE in BTBR mice, suggesting that BDNF-TrkB signaling plays a role in the EE-BTBR phenotype. Here, we used an adeno-associated virus (AAV) vector to overexpress the TrkB full-length (TrkB.FL) BDNF receptor in the BTBR mouse hypothalamus in order to assess whether hypothalamic BDNF-TrkB signaling is responsible for the improved metabolic and behavioral phenotypes associated with EE. Normal chow diet (NCD)-fed and high fat diet (HFD)-fed BTBR mice were randomized to receive either bilateral injections of AAV-TrkB.FL or AAV-YFP as control, and were subjected to metabolic and behavioral assessments up to 24 weeks post-injection. Both NCD and HFD TrkB.FL overexpressing mice displayed improved metabolic outcomes, characterized as reduced percent weight gain and increased energy expenditure. NCD TrkB.FL mice showed improved glycemic control, reduced adiposity, and increased lean mass. In NCD mice, TrkB.FL overexpression altered the ratio of TrkB.FL/TrkB.T1 protein expression and increased phosphorylation of PLCγ in the hypothalamus. TrkB.FL overexpression also upregulated expression of hypothalamic genes involved in energy regulation and altered expression of genes involved in thermogenesis, lipolysis, and energy expenditure in white adipose tissue and brown adipose tissue. In HFD mice, TrkB.FL overexpression increased phosphorylation of PLCγ. TrkB.FL overexpression in the hypothalamus did not improve behavioral deficits in either NCD or HFD mice. Together, these results suggest that enhancing hypothalamic TrkB.FL signaling improves metabolic health in BTBR mice.BTBR  Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterized by deficits in social communication and social interaction and by repetitive and restricted patterns of behaviors, interests, and activities . As of 2Past studies in our lab have extensively examined the effects of an enriched environment (EE) in a variety of mouse models of disease, including cancer and obesity. We have found that placing mice in an EE providing physical, social, and cognitive stimuli induces an anti-obesity, anti-cancer, and anxiolytic phenotype –10. We hT+ Itpr3tf/J (BTBR) murine model of ASD. We found that placing BTBR mice in an EE mitigated both metabolic and behavioral deficits. Enriched male BTBR mice displayed lower adiposity, increased lean mass, lower levels of circulating leptin, and improved glucose tolerance. Behavioral tests suggested that an EE decreased anxiety-like behavior and improved social affiliation. Gene expression of Bdnf was significantly upregulated, which was consistent with HSA axis activation. Gene expression of Ntrk2, encoding the BDNF receptor tropomyosin kinase receptor B (TrkB), was upregulated 3 to 6 folds in the hypothalamus, hippocampus, and amygdala of EE mice, an extent larger than Bdnf [Based on the beneficial effects we saw in models of obesity and cancer after EE intervention, we recently investigated the effects of EE in the BTBR han Bdnf .The BTBR mouse was originally bred for studies on insulin-resistance, diabetes-induced nephropathy and phenylketonuria . BTBR miOver a decade ago, researchers discovered that BTBR mice could be used as a model of ASD, as it displayed relevant key diagnostic symptoms of ASD—selectively reduced social approach, low reciprocal social interactions, impaired juvenile play, and repetitive behaviors . Since tBdnf and Ntrk2 were upregulated following EE. The actions of BDNF are mediated by two major TrkB isoforms—full length TrkB (TrkB.FL) and truncated TrkB (TrkB.T1) [Our previous cancer and obesity studies identified BDNF as the key brain mediator for improved metabolic and immunity outcomes following EE, and our EE-BTBR study found that TrkB.T1) . TherefoT+ Itpr3tf/J (Jackson Laboratory #002282) mice were used to investigate the effects of adeno-associated virus (AAV) mediated hypothalamic TrkB.FL overexpression. Five cohorts of male mice were used—a long-term (24 wks), NCD  fed cohort (n = 16); a long-term (23 wks), HFD  fed cohort (n = 11); a short-term (4 wks) NCD fed cohort (n = 10); a short-term (4 wks) HFD fed cohort (n = 10), and a short-term C57BL/6 NCD fed cohort (n = 10). Ages of the mice were 15–17 weeks old (long-term NCD), 4–5 weeks old (long-term HFD), 4 weeks old (short-term NCD), 8–16 weeks old (short-term HFD), and 7–9 weeks old (short-term C57BL/6 NCD). For the HFD cohorts, mice were fed HFD for five weeks prior to AAV injections and maintained on the HFD for the duration of the studies. Weekly food consumption and body weights were recorded. One mouse from the short-term NCD cohort and one mouse from the short-term HFD cohort died during the study and were excluded from subsequent analysis. Experimental timelines for the long-term NCD and long-term HFD groups can be seen in ad libitum access to food and water. All mice were group housed (3–5 mice) in standard laboratory environment cages and housed in temperature (22–23°C) and humidity (30–70%) controlled rooms under a 12:12 light:dark cycle. All animal experiments were approved by The Ohio State University Institutional Animal Care and Use Committee.Male BTBR GAATTCATGTCGCCCTGGCTGA-3’5’-AATTAA and reverse, GAATTCTTA CAGATCCTCTTCTGAGA-3’5’-AATATA. PCR product of TrkB-FL was then cloned into EcoRI site of the rAAV plasmid. The insert sequence was confirmed by sequencing at the OSU core facility. Amplified TrkB-FL retains a Myc tag at C-terminal before stop codon. rAAV plasmids containing TrkB-FL or yellow fluorescence protein (YFP) were packaged into serotype AAV1 vectors. The details of generation of rAAV were described previously [The rAAV plasmid contains an expression cassette consisting of the CMV enhancer and chicken β-actin (CBA) promoter, woodchuck post-transcriptional regulatory element (WPRE) and bovine growth hormone poly-A flanked by AAV2 inverted terminal repeats. cDNA of TrkB full length  was amplified by using a mouse clone of Ntrk2  as a template through polymerase chain reaction (PCR), with EcoRI flanking at each side. Primers for TrkB.FL amplification are as follows: forward, −1; i.p.) and secured via ear bars and incisor bar on a Kopf stereotaxic frame. A mid-line incision was made through the scalp to reveal the skull and two small holes were drilled into the skull with a dental drill above the injection sites . rAAV vectors (2.5 × 109 genomic particles per site) were injected bilaterally into the hypothalamus at a rate of 0.1 μl minute−1 using a 10 μl Hamilton syringe attached to Micro4 Micro Syringe Pump Controller . At the end of infusion, the syringe was slowly raised from the brain and the scalp was sutured. Animals were placed back into a clean cage and carefully monitored until recovery from anesthesia.Mice were randomized to receive either bilateral injections of AAV-YFP or AAV-TrkB.FL to the hypothalamus. Mice were anaesthetized with a single dose of ketamine/xylazine . Body composition analysis was performed with an echoMRI 3-in-1 Analyzer at the Small Animal Imaging Core of The Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University.ad libitum access to food and water. Mice were acclimatized in the metabolic chambers for 18 hours, then behavior and physiological parameters  were recorded for 24 hours at room temperature.At 17 wpi (long-term NCD) and 12 wpi (long-term HFD), mice underwent indirect calorimetry using the Oxymax Comprehensive Lab Animal Monitoring System (CLAMS) . Mice were singly housed with A glucose tolerance test (GTT) was conducted at 22 wpi (long-term NCD) and 11 wpi (long-term HFD). Mice were fasted for 16 hours overnight, then injected with glucose solution intraperitoneally (1.0 mg glucose/kg body weight). Blood was collected from the tail at baseline, 15, 30, 60, 90, and 120 minutes post glucose injection. Blood glucose concentrations were measured with a portable glucose meter (Bayer Contour Next).Methods for the behavioral assays can be viewed in Mice were sacrificed at 24 wpi (long-term NCD), 23 wpi (long-term HFD), and 4 wpi (short-term BTBR and C57BL/6 NCD and HFD BTBR). Mice were anesthetized by isoflurane and decapitated. Brown adipose tissue (BAT), gonadal WAT (gWAT), inguinal WAT (iWAT), and retroperitoneal WAT (rWAT), and liver were collected and weighed from both long-term groups. Gastrocnemius and pancreas were also dissected and weighed from the long-term NCD group. Hypothalamus was dissected from all groups. Tissues were flash-frozen on dry ice and stored at -80° C until further analysis.Hprt1 for hypothalamus and Actinb for adipose tissues and the relative gene expression was quantified using the 2 -ΔΔCT method [Total RNA was isolated from the hypothalamus, iWAT, gWAT, and BAT using the RNeasy Mini Kit plus RNase-free DNase treatment (Qiagen #74804). First-strand cDNA was generated using TaqMan Reverse Transcription Reagent (Applied Biosystems #N8080234). Quantitative real-time PCR was performed using Power SYBR Green PCR Master Mix (Applied Biosystems #A25742) on a StepOnePlus Real-Time PCR System (Applied Biosystems). Primer sequences can be viewed in T method .Hypothalamus, iWAT, gWAT, and BAT were homogenized in ice-cold Pierce RIPA buffer containing 1× Roche PhosSTOP and Calbiochem protease inhibitor cocktail III, then spun at 13,000 rpm for 15 min. Tissue lysates were separated by gradient gel  and transferred to a nitrocellulose membrane (Bio-Rad). Blots were incubated overnight at 4°C with primary antibodies listed in P ≤0.05 was considered statistically significant. Data were tested for normality using the Shapiro-Wilk test. If data violated assumptions of normality, either log2 transforms or Mann-Whitney tests were performed, and analysis was repeated. Welch’s correction was performed for data that violated assumptions of homogeneity of variance. Power analyses were conducted post-hoc. An ANOVA mixed effects model was used to analyze all longitudinal data, and Bonferroni’s test was used for corrections post-hoc.Data are expressed as mean ± SEM. GraphPad Prism 7 software  was used to analyze our data, using Student’s t-tests. We firstly assessed effects of hypothalamic TrkB.FL overexpression in BTBR mice fed on NCD . All outin vivo echoMRI was performed at 8 wpi to assess body composition. AAV-TrkB.FL mice displayed significantly decreased percent fat mass (P = 0.0086) and significantly increased percent lean mass as compared to AAV-YFP mice (P = 0.028)  .At sacrifice, tissue weights of iWAT, gWAT and BAT were significantly reduced  in the long-term NCD AAV-TrkB.FL mice as compared to AAV-YFP mice . When noWe next examined whether hypothalamic gene transfer of TrkB.FL alters obesity and associated metabolic dysfunction in obese BTBR mice. AAV-TrkB.FL and AAV-YFP mice had a significant weight difference at the start of HFD feeding and did not display significant differences in total weight gain over the course of the experiment . Due to At termination of the experiment 23 wpi, relative liver weight was significantly reduced (P = 0.0067)  while reIn our previous study investigating the effects of enriched environment on BTBR metabolism and behavior, we found significant differences between groups for the open field test and three chambered sociability, so we repeated those tests in this study. To measure anxiety-like behavior and locomotion, an open field test was performed at 12 wpi (long-term NCD) and 22 wpi (long-term HFD). Total distance traveled, distance traveled in the periphery/distance traveled total ratio, and distance traveled in the center/distance traveled total ratio were measured. There was no significant difference between AAV-TrkB.FL and AAV-YFP mice for any measures, in both the long-term NCD  and the Another test to measure anxiety-like behavior is the novelty suppressed feeding test, which was performed at 18 wpi for the long-term HFD group. Mice were fasted overnight and then placed in a new cage with a piece of chow. Latency to feed and food consumed were measured. No significant differences were found between AAV-TrkB.FL and AAV-YFP mice for either measure .In addition, long-term HFD mice were subjected to the third anxiety-like behavioral test, cold induced defecation test, at 18 wpi. Cold temperatures can induce stress in mice and stress increases defecation , 28. We For the long-term HFD experiment, the three-chambered sociability (3CS) test was conducted at 18 wpi. For the first phase, the time spent in the mouse-filled chamber, time spent in the center, and time spent in the empty chamber was recorded. The social affiliation index was calculated by taking the ratio of the time spent in the mouse chamber over the time spent in the empty chamber. No significant differences were found between AAV-TrkB.FL mice and AAV-YFP mice for any of these measures. For the second phase, the time spent in each chamber was recorded. The social novelty index was calculated by taking the ratio of time spent in the novel mouse chamber over the familiar mouse chamber. Again, there were no significant differences between AAV-TrkB.FL and AAV-YFP mice for any measures . In ASD Bdnf, Mc4r (encoding melanocortin-4 receptor), Vgf (encoding nerve growth factor inducible), Insr (encoding insulin receptor), Obrb (encoding long form leptin receptor), Crh (encoding corticotropin-releasing hormone), Npy (encoding neuropeptide Y), and Pomc (encoding proopiomelanocortin). Interestingly, both anorexigenic Pomc and orexigenic Npy were significantly upregulated in AAV-TrkB.FL injected mice   .Il1b (encoding interleukin-1β) (P = 0.037) while upregulated Apoe (encoding apolipoprotein) (P = 0.039). It is reported that BTBR mice show an increased proportion of MHC class II (encoded by H2ab1)-expressing microglia compared to sociable strain C57BL/6 [H2ab1 and Tnfa (encoding tumor factor-α) expression showed a trend of downregulation in the AAV-TrkB.FL mice although not reaching significance . No changes were observed among Il33 (encoding interleukin-33), Ccl2 (encoding C-C motif chemokine ligand 2), or Cx3cr1 (encoding C-X3-C motif chemokine receptor 1) (Neuroinflammation is implicated in the aberrant behaviors of BTBR mice . Accordi C57BL/6 . Hypothaeptor 1) .We profiled hypothalamic gene expression in the long-term HFD experiment including BDNF-TrkB relevant genes and the genes whose expression was altered by TrkB.FL overexpression in the long-term NCD experiment . TrkB.FLAdipoq , Hsl , Vegfa  and downregulated Lep  (Adrb3 (encoding adrenoceptor β3) expression in all adipose depots examined, gWAT (P = 0.0218), iWAT (P = 0.0226), and BAT (P = 0.0359). Ppargc1α  was upregulated in iWAT of TrkB.FL mice (P = 0.0095) , Elovl3 , Prdm16 , and Ucp1  were significantly upregulated in TrkB.FL injected mice  . Hypotha 0.0095) . In BAT,ted mice .The TrkB family includes at least three well-characterized TrkB isoforms through alternative RNA splicing. TrkB.FL is a receptor tyrosine kinase containing an extracellular ligand-binding domain, a single transmembrane domain, and a typical intracellular domain for tyrosine kinases. Two other isoforms (TrkB.T1 and TrkB.T2) are truncated for their intracellular kinase binding domain . TrkB.FLThree canonical pathways are activated following TrkB receptor activation—MAPK/ERK, PI3K/AKT, and PLCγ . BecauseTo determine which pathways were activated following TrkB.FL overexpression in obese BTBR mice, we carried out a short-term HFD experiment. Hypothalamic samples were collected at 4 weeks post AAV injection. As in the short-term NCD experiment, no changes in body weight were observed for this experiment . We perfTo examine hypothalamic signaling changes that occur following TrkB.FL overexpression in C57BL/6 mice of normal weight, we performed a short-term experiment mirroring the BTBR short-term experiments. Hypothalamic samples were collected 4 weeks post injection. There were no changes in body weight over the course of this experiment . Myc expIn this study, we found that hypothalamic TrkB.FL gene transfer in BTBR mice improved metabolic outcomes, but not behavioral deficits. Both long-term NCD and long-term HFD AAV-TrkB.FL groups displayed lower percent body weight gain in the absence of decrease of food intake. Long-term NCD AAV-TrkB.FL animals showed increased leanness and decreased adiposity as well as improved glycemic control. The effects of TrkB.FL overexpression on metabolic outcomes were not as drastic in HFD-fed animals as in NCD-fed animals, and TrkB.FL NCD-fed mice displayed lower relative weight of iWAT while HFD-fed did not show a difference between AAV-YFP and AAV-TrkB.FL. BTBR animals show metabolic impairments at baseline . It is pIl1b expression and alteration of the expression of some microglial-related genes in the hypothalamus of AAV-TrkB.FL injected mice. These molecular changes were observed in the long-term NCD study a few months after systemic metabolic effects occurred. We did not see these inflammatory changes in the long-term HFD study. Mice fed a high-fat diet display chronic hypothalamic inflammation [Pomc and Npy in TrkB.FL NCD mice, but not in TrkB.FL HFD mice. Pomc and Npy expressing neurons act antagonistically to control energy homeostasis, and a disruption in this system is associated with obesity. Particularly, a HFD downregulates Pomc and Npy [Pomc and Npy involved in HFD feeding. New studies are required to investigate whether the potential modulation of neuroinflammation and/or microglial functions is a direct effect of hypothalamic neuronal BDNF-TrkB activation, or alternatively, a feedback of the systemic metabolic outcomes induced by hypothalamic TrkB.FL.One notable finding of the study is the downregulation of proinflammatory ammation , 46. BDNammation , 48. It  and Npy , 50. AgaResearch points toward impaired neural circuit development as a potential cause of ASD. Due to the importance of neurotrophins in synaptic plasticity and neural growth and development, alterations in neurotrophin levels and their associated signaling pathways are one area of research into the pathophysiology of ASD in human subjects and in animal models of ASD . SeveralBdnf and its receptor Ntrk2 were both up-regulated, suggesting BDNF-TrkB signaling plays a role in mediating the EE-BTBR phenotype. Therefore, hypothalamic TrkB.FL overexpression in BTBR mice would also promote its downstream pathway signaling, thereby leading to the improved beneficial outcomes we saw in the EE-BTBR study.BDNF-TrkB activation initiates three main signaling pathways—MAPK, PI3K, and PLCγ. Activation of TrkB at its Tyr490 and Tyr515 sites results in recruitment of GTPase Ras, which activates the MAPK/ERK pathway. MAPK/ERK pathway activation ultimately drives BDNF expression to regulate neuronal survival, differentiation, and synaptic plasticity . RecruitIn the NCD group, strong Myc bands in the AAV-TrkB.FL group confirmed on-target transduction of the AAV vector . There win vivo in a Bdnf heterozygous knockout mouse partially rescued the obesity phenotype [In this study, we assessed the ratio of TrkB.FL to TrkB.T1. TrkB.T1 is a truncated isoform of TrkB that does not contain an intracellular kinase domain, and therefore it does not activate the classical signaling pathways associated with TrkB.FL. TrkB.T1 can bind BDNF to prevent activation of the MAPK/ERK, PI3K/AKT, and PLCγ pathways by forming a heterodimer with TrkB.FL, acting as a dominant negative inhibitor of TrkB.FL. Increased expression of TrkB.T1 can thus prevent BDNF mediated cell survival and proliferation . Our prehenotype . Here, TpPLCγ was significantly increased in the AAV-TrkB.FL group, leading us to believe that the pPLCγ pathway is important for the improved metabolic outcomes we saw in the NCD group. As previously mentioned, activation of the PLCγ pathway is important for synaptic plasticity. Over the course of the NCD experiment, AAV-TrkB.FL animals ate significantly more relative food , but gaiTo investigate a mechanism downstream of hypothalamic TrkB.FL signaling that may explain the improved metabolic outcomes, we profiled a number of metabolism related genes in iWAT, gWAT, and BAT. WAT and BAT make up an organism’s adipose organ. WAT stores excess energy and acts as an endocrine organ, while BAT is metabolically active and dissipates energy as heat for thermoregulation. BAT dissipates energy as heat through thermogenesis, whereby uncoupling protein-1 (UCP1) mediates the process of uncoupling fatty acid oxidation from ATP production . BAT is Adipoq was upregulated and Lep was downregulated and iWAT Adipoq was upregulated. This is consistent with the reduction in body weight we observed, as well as our previous studies showing that activation of the HSA axis increases adiponectin and decreases leptin in WAT adipocytes. β-adrenergic signaling is important for the activation of BAT in response to cold and for the regulation of adiposity and it also plays an important role in inducing beiging of WAT [Adrb3, suggesting increased sympathetic tone to the adipose tissues and possible induction of beiging in the WAT. Hsl was upregulated in gWAT of TrkB.FL overexpressing mice, suggesting increased lipolysis in WAT [Vegfa as a key component of the HSA axis underlying the beiging effect of WAT, likely directly caused by the SNS stimulation to the WAT [Vegfa expression in gWAT, suggesting beiging may be occurring in WAT. Ppargc1a encodes for PGC-1α, which has been shown to be an important modulator of UCP1 expression and thermogenesis in BAT and also plays an important role in the brown adipocyte differentiation process [Ppargc1a was upregulated in the iWAT of TrkB.FL overexpressing animals, which suggests beiging of WAT. Prdm16 controls a cell fate switch determining formation and function of brown adipocytes [Cidea, Elovl3, and Ucp1, which are all BAT selective markers and are positively regulated by Prdm16 [Based on these previous studies we hypothesized that overexpression of TrkB.FL, similar to upregulation of BDNF, would activate the HSA axis leading to adipose remodeling and metabolic improvement. Adiponectin and leptin levels are both associated with adiposity, with adiponectin expression being reduced as adiposity is increased, and leptin being increased as adiposity is increased . We foung of WAT , 71. We s in WAT . Our pre the WAT . We foun process . We founipocytes  and was y Prdm16 . OverallTrkB.FL overexpression resulted in signaling changes in the HFD group similar to those in the NCD group. Just as in the NCD group, TrkB.FL overexpression in the HFD group significantly increased phospho-PLCy, while there were no significant differences for phospho-AKT, phospho-ERK, PTEN, or Ras. Thus, it seems that the PLCγ pathway is important for the improved metabolic outcomes in both NCD BTBR mice and HFD BTBR mice. In the AAV-TrkB.FL animals, increased TrkB.FL levels and the increased TrkB.FL/TrkB.T1 ratio trended toward significance, but did not reach the highly increased levels found in the NCD study. In C57BL/6 mice, a HFD has been found to decrease hippocampal TrkB activation and expression and reduce activation of hippocampal BDNF-TrkB signaling pathways , 76. It’To investigate whether the effects of TrkB.FL overexpression can be generalized to non-BTBR mice, we injected C57BL/6 mice with either TrkB.FL or YFP and examined protein expression of signaling mediators downstream of TrkB.FL. Similar to BTBR NCD mice, we found that TrkB.FL overexpression altered the ratio of TrkB.FL/TrkB.T1. In contrast to BTBR mice we found that TrkB.FL overexpression did not upregulate pPLCγ, suggesting strain-dependent response to TrkB.FL overexpression in mice of normal weight. We did not perform behavioral testing for C57Bl/6J mice in this study. The purpose of including C57Bl/6J mice was to compare the changes in TrkB.FL signaling pathways following TrkB.FL overexpression between C57Bl/6J mice and BTBR mice. Because C57Bl/6J mice do not have baseline deficits in behavior and sociability like BTBR mice we did not expect to see any significant changes in these groups following TrkB.FL overexpression. We have not overexpressed neuronal TrkB.FL in C57Bl/6 mice before, but we have overexpressed neuronal BDNF in the same area of the brain. We found that in C57Bl/6 mice fed a NCD, overexpressing BDNF led to weight loss; reduced adiposity; a decrease in serum leptin, insulin, cholesterol, triglycerides, and IGF-1 and an increase in adiponectin; and altered expression of metabolism related genes in the hypothalamus and adipose tissue , 39. In Ntrk2 was significantly upregulated by 3 to 6 folds in the hypothalamus, hippocampus, and amygdala of male mice upon EE exposure [In our previous EE-BTBR study, we found EE improved metabolic outcomes and several behavioral measures. Because of our additional prior studies showing that hypothalamic BDNF mediates the improved metabolism and cancer outcomes in previous obesity and cancer EE studies, we hypothesized that TrkB signaling was also responsible for the outcomes we saw in the BTBR EE study. In the current study, we found that hypothalamic TrkB.FL overexpression specifically in the hypothalamus of BTBR mice improved the metabolic outcomes, but not behavioral deficits. This suggests that there is an additional mechanism responsible for the EE-induced behavioral improvements in BTBR mice. Much of the research surrounding BTBR behavior has focused on characterizing the behavioral phenotypes , 78 or aexposure . It is pexposure . Anotherexposure . These sexposure  while agexposure . Future Ntrk2 induced by EE was only observed in male mice [Another path to examine is sex differences. Our previous EE-BTBR study found significant sex-dependent outcomes. EE induced more robust improvements in metabolic outcomes in male mice, with only modest improvements in females. It is worthy of noting that upregulation of ale mice , which pale mice , so inveale mice , 8.One drawback to this study are the age differences and the differences in time points of metabolic and behavioral measurements between the long-term NCD group and the long-term HFD group. As such, we were unable to directly compare these two groups. Age-matched experiments would have allowed us to examine exact differences in response to hypothalamic TrkB.FL overexpression between BTBR mice of a normal weight and obese BTBR mice and controlled for possible age effects. Unfortunately, COVID-19 restrictions placed limitations on the timings of the experiments and breeding availability. Due to these age differences we must note that direct comparisons or concrete conclusions cannot be made regarding the differences between the long-term NCD and long-term HFD groups.To date, this is the first study investigating hypothalamic BDNF-TrkB signaling pathways and their impact on metabolism and behavior in the BTBR mouse model of ASD or in a diet-induced obesity BTBR model. Dysregulated BDNF-TrkB signaling has been implicated in both ASD and in obesity, with dysfunction of the hypothalamus being critical in obesity, but the changes in signaling mediators downstream of hypothalamic TrkB in BTBR mice have not been studied sufficiently. Here we provide evidence that hypothalamic TrkB.FL overexpression changes downstream signaling mediators, leading to improved metabolic outcomes in the BTBR mouse model of ASD.S1 Data(XLSX)Click here for additional data file.S2 Data(XLSX)Click here for additional data file.S3 Data(XLSX)Click here for additional data file.S1 Raw images(PDF)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 FigRepresentative image was taken at 10x magnification. ARC, arcuate nucleus; VMH, ventromedial hypothalamus.(TIF)Click here for additional data file.S2 Fig(A) Open field test total distance. (B) Open field test center/total distance ratio. (C) Open field test periphery/total distance ratio. Data are means ±SEM. AAV-YFP: n = 8, AAV-TrkB.FL: n = 8.(TIF)Click here for additional data file.S3 Fig(A) Open field test total distance. (B) Open field test center/total distance ratio. (C) Open field test periphery/total distance ratio. (D) Novelty suppressed feeding food consumed. (E) Novelty suppressed feeding latency to feed. (F) Cold induced defecation fecal boli. Data are means ±SEM. AAV-YFP: n = 5, AAV-TrkB.FL: n = 6.(TIF)Click here for additional data file.S4 Fig(A) Three chamber sociability social affiliation. (B) Three chamber test sociability social affiliation index. (C) Three chamber sociability test social novelty. (D) Three chamber sociability test social novelty index. Data are means ±SEM. AAV-YFP: n = 5, AAV-TrkB.FL: n = 6.(TIF)Click here for additional data file.S5 Fig(A) Body weight. Data are means ±SEM. AAV-YFP: n = 5, AAV-TrkB.FL: n = 4.(TIF)Click here for additional data file.S6 Fig(A) Body weight. Data are means ±SEM. AAV-YFP: n = 4, AAV-TrkB.FL: n = 5.(TIF)Click here for additional data file.S7 Fig(A) Body weight. Data are means ±SEM. AAV-YFP: n = 5, AAV-TrkB.FL: n = 5.(TIF)Click here for additional data file.


Older adults are at risk for severe disease following respiratory syncytial virus (RSV) infection. We assessed knowledge and attitudes regarding RSV infection and prevention among residents of long-term care facilities (LTCFs).Between October and December of 2021, surveys were administered to residents of LTCFs before and after 1.25-hour educational sessions led by health care professionals (HCPs) at 5 centers.P < .001) and less likely to utilize unreliable sources.Surveys were completed by 167 residents . Residents reported low levels of knowledge of RSV-related topics, which increased significantly after the sessions . Before the sessions, 43% used family/friends and social media to obtain information about RSV and other infectious diseases, while only one-fourth consulted an HCP to learn about these topics. After the sessions, residents were more likely to confer with their HCP (P = .016). After attending the sessions, more than 80% reported that they plan to get an RSV vaccine when one is available and be more diligent in taking actions to prevent the spread of infectious diseases.Although most residents indicated that they would get tested as soon as possible if they came down with symptoms suggestive of RSV or other infections, only 64% reported high confidence in preventing spread. Although most residents believed that it was important to get vaccinated against respiratory viruses and that FDA-approved vaccines are safe, only 48% would be very willing to get an RSV vaccine if available. This proportion increased to 74% after the educational sessions . Less than one-half were very comfortable sharing questions and concerns about vaccines with HCPs, which increased to 62% after the sessions (While residents of LTCFs recognize the importance of RSV testing and prevention, they exhibit low levels of knowledge about RSV-related topics, lack of confidence in reducing the spread of disease, discomfort in raising issues regarding vaccination with their HCP, and unwillingness to get the RSV vaccine once available. Educational sessions can help to narrow knowledge gaps, increasing the potential for changes in behavior related to RSV prevention.Stefan Gravenstein, MD, MPH, Genentech: Advisor/Consultant|Genentech: Grant/Research Support|Janssen: Advisor/Consultant|Janssen: Honoraria|Longeveron: Honoraria|Merck: Honoraria|Moderna: Advisor/Consultant|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Sanofi: Grant/Research Support|Sanofi: Honoraria|Seqirus: Grant/Research Support|Seqirus: Honoraria.


We numerically investigated the use of graphene nanoribbons placed on top of silicon-on-insulator (SOI) strip waveguides for light polarization control in silicon photonic-integrated waveguides. We found that two factors mainly affected the polarization control: the graphene chemical potential and the geometrical parameters of the waveguide, such as the waveguide and nanoribbon widths and distance. We show that the graphene chemical potential influences both TE and TM polarizations almost in the same way, while the waveguide width tapering enables both TE-pass and TM-pass polarizing functionalities. Overall, by increasing the oxide spacer thickness between the silicon waveguide and the top graphene layer, the device insertion losses can be reduced, while preserving a high polarization extinction ratio. Quantum Key Distribution (QKD) enables the provably secure distribution of private keys, relying on quantum mechanics fundamental principles . Silicon2). For the implementation of integrated QKD systems, on-chip devices are needed to accurately manipulate the polarization state of the light injected in photonic-integrated circuits (PICs). Polarizers, polarization beam splitters (PBSs) and polarization rotators (PRs) are employed to this aim. Polarization manipulation in PICs usually relies on an asymmetric waveguide design to allow the optical power transfer between orthogonal polarization modes [Graphene, 2D nanomaterials and semiconductor nanowires can be used to build nanodevices that are able to coherently and dynamically manipulate the photon polarization . In 2D mon modes . Birefrion modes . 5 cm2 V−1 s−1 at a ~1011 cm−2 electron concentration [2 buffer layer. A fabrication goal is to ensure a flat SiO2 surface for easy graphene transfer and patterning. The graphene transfer is usually efficiently performed using polymer-based pick-up techniques [At low doping, graphene operates as a TE polarizer, its conductivity being dominated by inter-band chiral transitions . When thntration . In thischniques . In prevchniques . Recent chniques . In partIn this work, we now propose a polarization control technique using graphene nanoribbons. In graphene–silicon heterostructures, optical absorption is allowed only for the fraction of the electric field that is parallel to the graphene plane, and the birefringent behavior thus takes place because this fraction is generally different for the TE and TM modes in silicon nanophotonic waveguides ,24,25. G2 deposited on a bulk Si wafer. All the standard optical components  are usually realized on the same PIC on a standard 220-nm-thick SOI platform. A critical task to be accomplished is the coupling of the light from (to) an optical fiber to (from) the PIC. The most common platform for PIC is silicon-on-insulator (SOI), constituted by a thin layer of Si lying on a thick  layer of SiOIn this work, we numerically analyze graphene’s capability of controlling the TE–TM polarization of light beams traveling down a coupled graphene-silicon waveguide. For this purpose, 2D simulations of the fundamental modes propagating in the waveguide under study have been carried out to characterize the different coupling of the modal electric field components in parallel and orthogonal directions with respect to the graphene sheet.wg, wgr and td), i.e., the silicon waveguide width, the graphene nanoribbon width and the oxide spacer thickness between silicon and graphene. A standard silicon-on-insulator (SOI) photonic waveguide is optically coupled to a graphene nanoribbon placed on top of the silicon layer. The upper oxide cladding provides electrical insulation between the graphene and silicon layers, with the possibility to locally create flat surfaces for easier transfer of graphene nanoribbons [wg of 450 nm and narrow 300 nm value, changing the graphene width wgr from 50 nm up to 3 μm and the top oxide thickness td from 10 nm up to 700 nm. In oribbons . In this15 rad·s−1  waveguides suffer from large polarization birefringence, because of the high refractive index contrast between silicon and silicon dioxide SiOτ = 20 fs. We can see that when increasing the chemical potential (cµ), the normalized effective refractive index of the TM mode grows more rapidly compared to that of the TE one, and that both have a maximum close to 0.4 eV; a further increase in the chemical potential leads to an interesting crossing, with the TE mode index exceeding that of the TM mode. Regarding the absorption losses, we see that at small cµ, the TE mode suffers much smaller losses compared to the TM one, while, with increasing cµ, the losses for the two modes progressively reduce and approach one another. The numerical analysis reveals that the cµ tuning affects the TE and TM polarizations in a similar way, while it has a different effect on the optical loss of the two modes (cµ > 0.5 eV.The presence of the graphene sheet modifies the propagation properties of these two modes, because of their overlap with the 2D material. The mode properties have been found to be strongly dependent on Graphene’s chemical potential. wo modes . We founcµ = 1.6 eV is shown in The spatial distribution of the TE and TM modes at chemical potential In In In cµ = 0.6 eV and the graphene electronic relaxation time to 20 fs, keeping it constant in all simulations, while varying the other geometrical parameters. As a general rule, an increase in graphene chemical potential helps in reducing optical insertion losses, at the expense of weaker interaction strength with the optical mode. Our first results (In our calculations, we study the behavior of the proposed device by setting the silicon waveguide width, the graphene nanoribbon width and the oxide spacer thickness as design parameters. As already reported in , graphen results , obtaine results .cµ tuning similarly affects both TE and TM polarizations, despite inducing different optical losses. We demonstrate that to reduce the optical losses, reasonable working points are the ones with the graphene chemical potential cµ > 0.5 eV. Another interesting and applicable result is that, when increasing the thickness of the oxide spacer between the silicon waveguide and of the top graphene layer, the device insertion losses are reduced, maintaining a reasonable polarization extinction ratio. The tapering of a standard waveguide can then be harnessed to create devices with TE-pass or TM-pass polarizing functionalities. These results are applicable to silicon photonics polarization-encoded QKD devices working in the telecom 1.55 μm C-band. In conclusion, we have presented the idea of a new architecture for TE–TM polarization control and tuning in SOI waveguides by means of graphene nanoribbons. The graphene material has been modeled as a two dimensional 2D boundary conditions using the Kubo formula for surface conductivity. By performing numerical analysis, we found that the


To identify and prioritise the most impactful, unanswered questions for obesity and weight-related research.Prioritisation exercise of research questions using online surveys and an independently facilitated workshop.Online/virtual.We involved members of the public including people living with obesity, researchers, healthcare professionals and policy-makers in all stages of this study.Top 10 research questions to be prioritised in future obesity and weight-related research.Survey 1 produced 941 questions, from 278 respondents. Of these, 49 questions held satisfactory evidence in the scientific literature and 149 were out of scope. The remaining 743 questions were, where necessary, amalgamated and rephrased, into a list of 149 unique and unanswered questions. In the second survey, 405 respondents ranked the questions in order of importance. During the workshop, a subset of 38 survey respondents and stakeholders, agreed a final list of 10 priority research questions through small and large group consultation and consensus. The top 10 priority research questions covered: the role of the obesogenic environment; effective weight loss and maintenance strategies; prevention in children; effective prevention and treatment policies; the role of the food industry; access to and affordability of a healthy diet; sociocultural factors associated with weight; the biology of appetite and food intake; and long-term health modelling for obesity.This systematic and transparent process identified 149 unique and unanswered questions in the field of obesity and weight-related research culminating in a consensus among relevant stakeholders on 10 research priorities. Targeted research funding in these areas of top priority would lead to needed and impactful knowledge generation for the field of obesity and weight regulation and thereby improve population health. This is the first research priority setting specific to the field of obesity and weight-related research.This exercise involved input from a large number of participants from a broad range of relevant stakeholder groups including patients, members of the pubic, researchers, policy-makers and charities.The final list of priorities was reached through consultation and consensus in a workshop guided by independent facilitators to minimise bias towards certain questions or areas.2 (or ≥30 kg/m2 if of white ethnic groups). No country has managed to achieve a sustained decrease in the prevalence of obesity, despite evidence-based clinical and public health guidelines and polices aimed at tackling obesity.Obesity is a major preventable cause of ill health and is affecting an increasing number of children and adults globally.Presently, the research agenda is mainly driven by the interests and concerns of researchers, or research commissioners. A more transparent, systematic and collaborative approach involving multiple stakeholders to identify research priorities could accelerate progress. The James Lind Alliance (JLA) priority setting process brings patients, carers and clinicians together on an equal basis to define uncertainties, consider their importance and thereby set research priorities.We involved two members of the public (BC and PS) with lived experience of overweight in all stages of the project, from conception and design of the study, to its conduct, data collection and analysis. Our wider public involvement (surveys and workshop) incorporated members of the public with and without lived experience of being overweight and patients, defined as people with lived experience of being overweight and experience of receiving clinical treatment for overweight, obesity or an associated condition. Members of the public were involved in all stages of the work alongside and as equal partners with other stakeholders.et al,et al.The priorities for obesity and weight-related research (POWeR) project took place between December 2019 and December 2020. The process was guided by Viergever Gathering questions:The first survey in the process asked respondents to submit up to four questions that they felt should be prioritised in the field of obesity and weight-related research. The survey was administered online using JISC Online Survey and was piloted with our public coauthors and colleagues in the research team, prior to being launched. The survey asked respondents to identify research questions that they felt were the most important unanswered questions on the topic and to say why they felt each question was important. The latter information was used by the team to interpret, contextualise, group and sort questions.https://www.phc.ox.ac.uk/research/participate/power), and actively via email to relevant stakeholders and Facebook adverts targeted to men. We invited our stakeholders to circulate the link, resulting in the distribution of the survey by more than 40 organisations to their members, visitors to their webpages and readers of their newsletters  systematic reviews published within the last 10 years, with little to no uncertainty; (2) proof of evidence in national clinical guidelines . We also accepted primary literature by way of high certainty if there was evidence in randomised controlled trials (RCTs). Such an approach would indicate that the question on currently available pharmacotherapy for obesity, for example, was at least partially answered by current reviews and trials.We noted how many questions fed into each research question.The second online survey was piloted with members of the public and colleagues in the research team. The survey was administered via REDCap, and sent to the 256 survey 1 respondents who had provided us with their email addresses, as well as to the organisations approached to share survey 1 see .The second survey remained open for 30 days between 6 August 2020 and 14 September 2020. Survey 2 asked respondents to prioritise the unanswered questions gleaned from survey 1, which were sent in batches of about 50 questions to lower the response burden. The questions in each batch covered the whole range of submitted research questions. Respondents were asked to rate each question on a scale of 1–10 with 10 representing ‘very important’ and 1 representing ‘not important’. The mean priority score was calculated for the resulting rated questions and ranked  to creatWe invited a subset of survey respondents and other stakeholders including NGO representatives, healthcare professionals, public members including people with lived experience of overweight to take part in a 3-hour online workshop in the winter of 2020 to determine the top 10 questions. This was a real-time, facilitator-led consultation, replacing a full-day in person event that was not possible due to local COVID-19 restrictions. The group was representative of the multidisciplinary stakeholders involved in the project; patients and members of the public, researchers, policy-makers, clinicians and relevant research funders. The workshop was held via a videoconferencing platform (Zoom), and led by external facilitators from Hopkins van Mil, a service that specialises in guiding impartial discussions to elucidate views and opinions of a diverse group of people in a safe, productive space.The 3-hour workshop was divided into three parts with a final plenary session. Throughout the workshop participants were asked to justify their choices, and reveal the values and reasoning behind their prioritisation. Important questions were defined as those that would have the most impact if answered by research. In the first session, each group was asked to debate what they considered to be the four most and least important research questions from the 30 questions. In session 1, the highest and lowest questions were determined.In session 2, facilitators shared a list of questions that were of medium importance, that is, not the highest or lowest priority questions determined in session 1. Facilitators asked participants to categorise these as either: (1) a priority, (2) low priority, (3) not a priority. This was determined by debate, discussion and justification of the participants’ reasoning. The facilitator moved the questions around on the shared slide. The highest ranking questions from session 1 and session 2 were brought together. By the end of the second session each group had a list of top 14 questions ranked in order of importance.The facilitators then met to combine the top 14 questions from all the small groups, this led to one list of 16 questions. In the third session of the workshop, this combined list of 16 questions was shared with the individual groups for debate. Here the groups were asked to determine and rank their final list of 10 research questions. Facilitators guided this final prioritisation stage by asking groups to focus on questions that would have the highest impact if taken forward as a research question. The groups then came together in a final plenary session and the top two questions from each group were shared with the larger group. After an amalgamation of the top two questions from each group and invariable overlap, the third and fourth questions from each group were added to produce a final list of the top 10 questions.https://www.phc.ox.ac.uk/research/participate/powerThis three-stage prioritisation project involved a diverse group of stakeholders in prioritising a list of top 10 unanswered research questions for obesity and weight-related research, which are presented here and at: Demographics of respondents and questions gathered:Survey 1 received 278 responses , yieldinfigure 1Box 1What are the most effective methods for weight maintenance following weight loss? What are the effective components of treatments/programmes incorporating a behavioural element? How many and in what combination are most effective? What is the optimal duration of these programmes?What are the most effective methods for weight loss? What are the effective components of treatments/programmes incorporating a behavioural element? How many and in what combination are most effective? What is the optimal duration of these programmes?What is the most effective and cost-effective mix of population/public health and individual interventions to tackle obesity?Do interventions that target the ‘obesogenic environment’, such as community interventions, urban planning, placement of fast-food outlets or workplace polices, affect population mean weight and do these effects differ by baseline weight status ? Which interventions are most effective at reaching low socioeconomic groups?Do interventions  in preschool, primary school and secondary school reduce children’s risk of unhealthy weight gain and, if so, how do they act? Does the effect of such interventions differ by social and cultural groups?What changes in supermarkets or the wider food industry are effective in promoting healthier diets? Does changing labelling and/or packaging on foods affect purchasing, consumption and body weight?What is the cost and affordability of a healthy balanced diet? How can we make healthier foods more affordable? How can we improve access to healthy diets for social and cultural groups, such as people in poverty, people in inner cities, or young and older people?How do demographic, social and cultural factors  affect weight status, weight gain and regional fat distribution? What are the mechanisms involved? Does the effectiveness of weight loss methods depend on social and cultural background and, if so, can the effects be made more equitable? Are weight loss methods tailored to people’s background more effective for weight loss and weight maintenance than general methods?How accurate are existing models of health consequences of excess weight and the impact of weight loss? Which assumptions are critical in determining the long-term effectiveness and cost effectiveness of weight loss interventions? What do these models predict is the impact of weight loss interventions on health and disease incidence and the cost-effectiveness of such interventions? What is the impact of weight regain on the incidence of disease and cost-effectiveness of weight loss interventions?What are the drivers of food choice, appetite and intake and do variations in these drives explain who develops obesity and who does not? How does the brain control food intake and can we use these mechanism to aid weight loss? What are the brain responses  in response to food during weight loss and following weight regain?Identifying unanswered questions:The 941 questions were grouped by topic. We excluded 49 (5.2%) questions as already answered, and 149, (15.8%) as out of scope . The remSurvey 2 received 405 responses; 61% of respondents reported lived experience with obesity and 74% held an education to degree level or above . A totalWe invited 64 stakeholders, 39 people confirmed their acceptance and one person dropped out on the day. Thirty-eight attendees  were made up of 4 public members, 8 participants from related organisations, 13 researchers, 7 policy makers and 6 healthcare professionals. One person asked for the question on the role of the gut microbiome to be included from the list of 10 extra questions. At the workshop 31 questions were debated in small groups. In the first session the groups sorted questions into highest and lowest priority. In the second session, the top 14 questions were determined by all groups except one that determined their top 10 and another that grouped questions as high medium and low priority. The facilitators combined the lists from all the groups into a list of 16 as many of the top 14 from each group overlapped. In the third session participants ranked the 16 questions into a top 10 list. The top two from all these lists was shared at a final plenary session. Consolidation of the top two questions and the questions ranked third and fourth resulted in 11 unique research questions by the end of the workshop. On analysis of recordings of each group’s discussion, multiple participants noted that two questions in the 11 that were similar in meaning. We, therefore, combined these two questions  post hoc to produce a final list of the top 10 research questions . There wOur priority setting exercise identified the top 10 research questions that stakeholders in the field, and those with an interest overweight and obesity, believe to be the key priorities to advance obesity and weight-related research. In two online surveys and a workshop, we collated nearly 1000 questions, and guided participants in a structured and systematic prioritisation process to reach the final list of 10 . These qThe main strength of this project was the successful collaboration between a diverse range of stakeholder groups, though it was not without its challenges. Our stakeholders included patients, members of the public, clinicians, charities, researchers and policy-makers connected to the field. Identifying the most appropriate group for a condition where a third of the adult population are clinically obese and more than 60% are overweight, while at the same time, considering how to prevent the condition developing which is relevant to the whole population, resulted in the inclusion of both patients and members of the public. Members of the public naturally included some people without lived experience of overweight or obesity, though it seems unlikely that they would not be aware of family members, and friends who are affected, and they may become affected themselves, justifying their inclusion in this prioritisation process. To have found consistency in the questions being posed throughout the entire process by a variety of individuals bringing different experience and expertise to a common area of focus, supports the validity of the resulting top 10 questions. The majority of survey respondents and workshop participants appear to be highly educated. Nonetheless there was evidence of an awareness of the need for interventions to help reduce inequalities and the top 10 priorities include questions on social determinants of health like low-socioeconomic status and cultural factors. We commissioned third-party, impartial facilitators to guide the workshop without input from the research team, so as to not inadvertently sway the prioritisation of questions being considered in each session. Additionally, the number of questions submitted and finally categorised is in line with similar priority setting exercises in health research, using an analogous process set out by the JLA, with a comparable number of stakeholders involved.13 14There are limitations that we identified and strived to address throughout the stages of the process. To begin with survey 1, we deemed that 5.2% of all questions submitted were already answered by empirical evidence. We assessed this through a thorough search of the literature to identify systematic reviews, clinical and public health guidelines and high-quality primary studies in the form of RCTs. Although this necessitated some subjective judgement, we ensured that all decisions were made in duplicate, and discrepancies were resolved by a third researcher. Our confidence in the categorisation of answered versus unanswered questions is strengthened by consensus among stakeholders involved, some of whom were researchers with expertise in the question areas being considered. That 5.2% of the submitted questions were considered answered indicates that research may not being adequately communicated in these areas. This could be addressed by improved or targeted communication.In survey 2, we asked participants to rate questions on a scale of 1–10, but found that participants were disinclined to use the full range. Many questions had means between 6 and 8 meaning that differences in the scoring were subtle. Future work could consider using a condensed scale to perhaps mirror ratings that people are more familiar with (eg, 5-point ratings seen in 5-star reviews or 4-point grading of evidenceAn additional limitation of the workshop was the shift to a virtual vs in-person meeting due to local COVID-19 restrictions, which limited the length of the discussions. On analysis of the recordings from each group’s consultations, it was clear that the virtual setting maintained a clean discussion where moderators were clearly able to garner input from each participant without anyone talking over-another, as may have been the case in an in-person discussion. It was possible to rank the top 10 in the small groups in the workshop, however, it was harder to achieve this with 38 participants in the plenary sessions so we did not seek to order the final 10 priorities. Lastly, obesity is a worldwide problem calling for a global research response, but we only involved UK-based stakeholders. It is likely that the process identified questions that are generalisable outside of the UK, but it is unlikely that this process fully captured priorities that may be relevant to low-income countries or countries with a low prevalence of overweight and obesity.The main implication of this work is for the top 10 POWeR to be considered by funding bodies concerned with advancing the field. Similar priority setting work in other areas of health research have resulted in research calls that reflect priorities identified by stakeholders.We make two recommendations for future priority setting exercises in this area based on what we learnt from the process. The first would be to limit the focus to a prespecified area in the field. The breadth of topic areas produced by the large number of stakeholders engaged was onerous to process, and resulted in high level areas for research. Future exercises may wish to restrict their scope to a certain area of research, such as treatment for people living with obesity, or population-wide prevention strategies to allow more granular questions to emerge. The second would be to incorporate work to boost awareness of the existing research evidence for common questions that were submitted, but deemed to be answered. Questions that were commonly submitted, but already answered and therefore excluded from progressing through the prioritisation process are telling of a discrepancy between published research and knowledge dissemination.We have identified 10 priorities that cover: the role of the obesogenic environment; effective weight loss and maintenance; prevention in children; effective prevention and treatment policies; the role of the food industry; access to and affordability of healthy diets; the sociocultural factors associated with weight; the biology of appetite and food intake and long-term health modelling. Research funders may want to prioritise these questions when considering research proposals, or commissioning programmes of research to answer these key questions.


We developed a brief cognitive behavioural, one-to-one intervention to reduce fatigue impact for patients with inflammatory arthritis. This qualitative process evaluation explored intervention acceptability and potential refinements from the perspective of patients who attended sessions and rheumatology health professionals (RHPs) who delivered the intervention.Interviews were conducted with patients and RHPs from five National Health Service (NHS) sites. Data were analysed using inductive thematic analysis.Twenty-two patients and 11 RHPs participated.Collaborative, non-judgemental consultations: patients valued having space to reflect, where their fatigue was validated. Relevant content, but not ground-breaking: patients appreciated the opportunity to tailor content to individual priorities. Daily diaries were useful to visualize fatigue. Self-awareness: patients reported increased acceptance, sense of control, and confidence to manage fatigue. Degrees of openness to change: sessions prompted patients to engage in behaviour change. For some, complicated lives made it difficult to plan for change.vs clinical practice: RHPs expressed concern about fitting sessions into NHS clinic appointments. It was difficult to offer follow-up sessions within 2 weeks. Collaborating with patients: RHPs reported that patients engaged with the tools and strategies. Some RHPs followed the manual in a linear way, whereas others used it flexibly.Engagement with intervention: RHPs liked training face to face, and sessions were more enjoyable with experience of delivery. Research There is potential for this brief fatigue intervention to benefit patients. Future research will focus on flexibility to fit with local services and creating educational resources to use in a range of contexts. Key messagesPatients valued the collaborative, therapeutic approach of sessions, describing increased feelings of acceptance and control.Rheumatology health professionals liked and enjoyed delivering the sessions, but it was difficult to fit into clinics.Potential refinements include developing content that can be applied in varying contexts and formats.Fatigue is a common, overwhelming and unpredictable symptom in inflammatory arthritis , 2, likeCognitive behavioural therapy is one of the most helpful types of support for inflammatory arthritis-related fatigue. Previous systematic reviews provide evidence that self-management courses that use cognitive behavioural therapy to increase self-efficacy (beliefs in the ability to carry out self-management behaviours) are more effective than interventions delivering information alone .A team from psychology, nursing and occupational therapy designed a brief, low-intensity intervention to address the impact of fatigue on patients with inflammatory arthritis, to be delivered by trained rheumatology health professionals (RHPs), using a manual, over two to four sessions. The first two core sessions were designed to take place face to face and within 2 weeks of each other. Two additional optional sessions could take place face to face or remotely, within the subsequent 4 weeks. It was tested in a feasibility study  .The intervention aims to reduce the impact of fatigue by encouraging patients to link thoughts, feelings and behaviours influencing their fatigue and their responses to it. Requiring buy-in from both patients and RHPs, the intervention uses an ‘ask, don’t tell’ approach, based on techniques of guided discovery and Socratic questioning . The aimThis paper reports on the findings of a qualitative process evaluation nested within FREE-IA, which played a vital role in understanding the acceptability of the intervention from the perspectives of two groups: the patients who attended sessions and trained RHPs who delivered sessions. It also explored how contextual factors might affect implementation, both as a larger national research study and into normal clinical practice. The aims were to understand the acceptability of the intervention and to identify potential refinements to the intervention.Six weeks after the first session, the study coordinator telephoned patients to collect their fatigue score. During this call, patients were asked if they would like to take part in an optional telephone interview to discuss their views and experiences. If they agreed, a consent form and information sheet were posted to the patient, and contact details were forwarded to the process evaluation research fellow (A.B.).The RHPs were recruited via their local principal investigator and were provided with information sheets explaining that they would be invited to take part in an interview. Consenting patients and respective RHPs provided written informed consent by completing the consent form and returning a copy to the study team before interview.Two distinct qualitative data sets were collected from patients who participated in FREE-IA sessions and RHPs who undertook FREE-IA training and delivery.Rheumatology Advances in Practice online). Patients were asked about the content and acceptability of the intervention. The RHPs were asked about training and the potential for integrating the intervention into clinical practice. Interviews were audio-recorded, transcribed verbatim and anonymized.Data were collected via one-to-one interviews by telephone. Interview questions were developed with collaborators and patient partners Just that the fatigue is acknowledged … having a medical professional sit in front of you and say, ‘This is a thing … we understand it’s a thing, we can’t explain why it’s a thing and we can’t give you a tablet to fix it, but we understand it is a thing’.(D466)Patients reported developing positive therapeutic relationships with experienced and knowledgeable RHPs. They felt it was beneficial to have their fatigue validated and to have time and space to reflect on its impact.Talking through my specific challenges with a bit of space, and a specialist to give me fresh ideas and not judge me … that one-to-one support and the time to talk about it has been very, very welcome … very, very, helpful.(D468)They found the ask don’t tell approach helpful and expressed their preference for a responsive, flexible approach to sessions, rather than a rigid, protocolized approach.It reinforced really what I should do, and what I needed to think about, and that was helpful. … I mean I knew about trying to get proper sleep and relaxation. Trying to pace oneself, those kinds of things. It’s a case of understanding this, you don’t always remember to do it like that.(C343)Patients appreciated the range of topics covered and valued the ability of RHPs to tailor content to individual priorities. Some had explored the topics covered previously; however, using visual illustration, for example, to communicate complex issues was very useful and prompted new ways of looking at the issue.You don’t make any real connections, but when you see it … that was a very good visual clue, and I didn’t think that was going to be useful, but actually, I found probably the most useful. It’s such a visual representation of what you are doing or where you are slacking or crashing or whatever it may be.(D465)That was the biggest wake-up call for me … looking at the activity diary. Until you look at it—you could see that I didn’t have any pattern or any sort of resemblance to any normality at all. Everything was just chaos.(B221)Being able to visualize the impact of lifestyle patterns on their fatigue using the daily activity diaries was helpful.It just feels like I’ve got more control over fatigue … it’s given me permission and a licence to give myself that care, which I don’t think I was allowing myself before.(D468)Some days … take you into nothing but red activity, and today is heading in that direction. I will be ill if I allow that to happen, therefore it’s in my control. I can either do something about it and not feel so bad tomorrow or ignore it and not be able to get up tomorrow.(B229)Sessions increased patients’ awareness of lifestyle factors and patterns influencing their fatigue, which increased their sense of control and confidence to manage fatigue.It’s not the be all and the end all now. I accept it is part of the condition, I accept that it might be there more prominent some days than others or some weeks than others. And there’s no point worrying about it.(A103)Patients also highlighted how the sessions helped them to accept their fatigue, with this reflective process giving them ‘permission to relax’.It started me … paying a bit more attention to things like sleep and diet and lifestyle, but actually specifically thinking about how those could affect the fatigue. … I’m sure the sessions helped with that.(C344)Sessions prompted some patients to engage in positive behavioural change, such as adapting sleep patterns, pacing, planning and setting goals.It’s very easy to get into a rut and just do each day as it comes, and don’t even think about going forward or anything else. … Having things to aim for … I have already booked a few things and doing things in the future.(D465)For others, the sessions ‘sowed the seeds’ and led to planning for future lifestyle changes.I think my condition is governing my fatigue and I don’t think there’s anything that … I think it is what it is, and I think for me the big thing is being more aware of it.(D461)However, some patients felt that any change in lifestyle would not affect their symptoms of fatigue.For some participants, the broader effects of complex lifestyle situations meant it was difficult to consider or plan for change. Co-morbidities, work and family commitments and lack of finances meant that engaging with positive lifestyle changes was impossible.Eight RHPs participated in interviews, and three RHPs provided data via email. Three themes capture their views and experiences.You get much more engagement when you’re face to face and you’ve got the different dynamics going on in the group … we would discuss the course together and different opinions … I thought it was really good.(ATTM1)The RHPs valued the face-to-face training delivered by the FREE-IA team and learning with peers, describing sessions as providing an opportunity to share ideas for learning.We all came out all guns blazing (following training), and then … it was a long time before we were able to get on the ground and see people. You kept re-reading the book, but I think it would have been probably better from my idea to have a refresher.(ETTM1)Some RHPs felt they would have benefitted from refresher training, when starting the sessions was delayed for local logistical reasons.As I’ve been doing the sessions, the more confident I’ve got, part of it is knowing the people, but also knowing the material as well. I’ve really enjoyed it, because you can see how much a patient is getting out of it.(CTTM1)Yes, ‘ask, don’t tell’—very, very difficult. Because, I mean, by nurses … by definition, we advise our patients on theoretically what we think is best for them … it was quite hard to let go. That was very new. … I think familiarity … the more I did it, the easier it became.(ETTM1)For RHPs with extensive experience of providing fatigue support, the low level of treatment intensity and manualized approach limited the usefulness of the intervention. This led to a lower level of engagement and satisfaction compared with RHPs who had fewer resources to use with patients. Conversely, those with less experience of providing fatigue support before the study reported gaining confidence as they delivered more sessions.If we were to focus on fatigue alone, no it wouldn’t (work) … if it’s like a five-minute discussion on fatigue and how to manage it, then that’s fine … but anything longer than that … we wouldn’t fit it in.(BTTM1)Sessions were often carried out outside of usual clinics, or at the end of a clinic in order that more time could be allocated if needed. The RHPs expressed concern about fitting sessions into clinic appointments, because a number of sessions lasted longer than the 20–30 min suggested length. Sessions ranged from 10 to 120 min, with an average (median) of 40 min.That was quite difficult because of the waiting list I have. Getting them in the first time was all right, but getting them in for the second appointment within a fortnight was quite difficult.(ETTM2)It was a challenge to offer patients a follow-up session within the desired 2-week time frame, because of long waiting times and a high demand for available clinic appointments.I have already taken advice from the manual and repeated it to patients in clinic. Snippets of useful information is a quick and easy way of helping patients when I am more pressed for time in a ‘normal’ clinic setting.(DTTM1)Some RHPs described integrating the intervention approach and materials into their routine interactions with patients.Obviously, the activity diaries … I think they look at it, not realizing the actual impact it has, once they’ve done it … they don’t realize until they do it.(CTTM1)The RHPs reported that patients were willing to try the tools and strategies during the sessions. Some RHPs followed the manual in a linear way, whereas others adapted content and used it more flexibly.Most of the ones who contributed to the study are proactive and want to change, and they are willing to make changes. And then you have got other patients … who think that we can fix them by giving them a tablet, and we can’t. And they put up obstacles about everything you say … but I understand it’s hard…(BTTM1)The RHPs also reflected on those patients who did not engage, expressing that some might require a higher-intensity approach and level of support.A key finding within this study was the value of the collaborative, ‘ask, don’t tell’ approach adopted in sessions. Having space and time to discuss the impact of fatigue and having it validated by a health-care professional was empowering. Patients and RHPs described how this approach enabled them to develop positive therapeutic relationships. Some RHPs found using the approach challenging, and this is where more training or experience of the intervention could have strengthened skills and confidence levels of the RHPs.These findings align with previous literature that highlights the importance of shared decision-making and collaborative working relationships . They stPatients and RHPs highlighted the value of particular tools and approaches, such as using the daily diaries to visualize lifestyle patterns. It is important to recognize elements of the intervention that might be incorporated more easily than others. Adapting the daily diary tool for use in everyday clinics could be explored in future research.The RHPs became more confident about the (often new to them) interventional approach and content as they delivered more sessions. These findings support earlier fatigue studies  and litePatients valued working with a health professional who was familiar to them. The RHPs were able to deliver the sessions, but reported barriers to implementing the intervention into normal practice (in its current format) owing to short clinic appointment slots and the inability to carry out the second session within 2 weeks. Some RHPs had adopted certain tools and topics, using them in everyday clinic appointments. This is an important finding and highlights the possibility of adapting intervention content to make it more acceptable and exploring how it could be incorporated better into a clinical setting.For some participants, the broader determinants of health impacting levels of fatigue were complex and multidimensional, and factors such as disease activity meant that it simply was not the right time for change. These findings highlight that a low-intensity intervention will not be adequate for all patients experiencing symptoms of fatigue, but recognizing that it has a place within a ‘stepped approach to care’ , being bThis study was able to uncover the experiences and attitudes about the sessions from the perspectives of both the patient and the RHP. It demonstrates sensitivity to context and the wider determinants affecting fatigue, in addition to highlighting the importance of the collaborative approach of the sessions. The methods adopted were able to unpick the workings and nature of the sessions, including issues affecting approach, content and delivery.The sample was recruited from across all five NHS sites and included participants who had attended between one and four sessions to gain insight into their reasons for opting to take part in more or less of the intervention. Recruitment occurred throughout the course of the study, enabling the sample to include patients who had sessions with RHPs who had differing levels of experience of delivery. Two patient research partners were involved in the design of the study; this included feedback on patient information sheets and interview questions.The sample size, although relatively small at 22, was close to half of the total number of 46 patients who attended sessions; however, ethnic minority communities were underrepresented in the sample. We also collected no data on the health literacy levels of the patients, which are known to affect self-management strategies in rheumatology . It is aA sensible next step is to explore options for alternative modes of intervention delivery and, importantly, how the essence of the sessions, including the approach and tools, might best be translated. The move to online consultations since the coronavirus disease 2019 (COVID-19) pandemic in 2020 opens up the opportunity for more patients to engage with RHPs, but also presents challenges in terms of accessing intervention resources and working collaboratively. Digitalized content could make it easier for RHPs to provide guidance and copies of the diaries before the first session, meaning that lifestyle patterns can be explored together in the initial session.Arguably, online working shows potential for how it might be possible to integrate such sessions into clinical appointments. It would be of value to explore this further with RHPs post-COVID-19, in addition to observing what the ‘new normal’ looks like for different rheumatology clinics nationally.Given the findings of the importance and value of the collaborative nature of the sessions, future research should explore whether and how this approach translates into the digital consultation, and if it is affected in any way, from the perspectives of both the patient and the RHP. Future research will focus on adopting new ways of integrating sessions and content into potentially digital consultations and developing content that can be used in a range of contexts and formats.This study reports on the acceptability of a brief, cognitive behavioural, one-to-one intervention to reduce fatigue impact within the NHS. The study presents novel key issues regarding the usefulness for this new intervention and demonstrates the potential for this intervention to benefit patients. Collaborative, positive therapeutic relationships were able to be established between patients and RHPs within a short period of time, and patients described feeling empowered, more in control and confident to address lifestyle patterns and consider positive behavioural change to improve self-management of their fatigue.rkac064_Supplementary_DataClick here for additional data file.


Both these two parameters can be used to sense different breathing conditions, such as normal breathing and deep breathing, and breathing with different rates such as normal breathing, slow breathing, apnea, and fast breathing. Experimental results also indicate that the proposed humidity sensor has potential applications in predicting the fitness of individual and in the medical field for detecting body fluids loss and daily water intake warning. The respiratory rates measured by our proposed PI-FBAR humidity sensor operating in frequency mode and S11 mode have Pearson correlation of up to 0.975 and 0.982 with that measured by the clinical monitor, respectively. Bland–Altman method analysis results further revealed that both S11 and frequency response are in good agreement with clinical monitor. The proposed sensor combines the advantages of non-invasiveness, high sensitivity and high stability, and it has great potential in human health monitoring.Respiration monitoring is vital for human health assessment. Humidity sensing is a promising way to establish a relationship between human respiration and electrical signal. This paper presents a polyimide-based film bulk acoustic resonator (PI-FBAR) humidity sensor operating in resonant frequency and reflection coefficient S Respiration is one of the vital signs of human beings because it can help assess an individual’s health condition and screen for early diseases based on information from respiratory rate and depth. Abrupt changes in respiration rate and depth often indicate the occurrence of illnesses, such as heart disease, bronchitis, asthma , pneumonRecently, humidity sensors with merits such as fast response, high accuracy, and reliability have been emerged as great candidates for the application in respiration monitoring, which is achieved by measuring changes in humidity during exhalation and inhalation. The drop in local relative humidity (RH) during inhalation, due to the air flow taking away the water vapor, and a subsequent rise in local relative humidity during exhalation due to the increased outflow of water vapor in the breath, happen during respiration, irrespective of the relative humidity of the environment. Therefore, relative humidity sensor-based respiration monitoring is less affected by the environmental conditions as compared to the mechanical sensors, conventional air flow meters and thermal sensors. Generally, there are various kinds of humidity sensors, such as optical fibers ,8,9, capA lot of effort has been invested to realize high-performance FBAR humidity sensors. Hygroscopic materials such as polymers , graphen11 [11 response of the PI-FBAR humidity sensor [11 has not been systematically studied. In addition, as far as we know, there is no report on human respiration monitoring based on FBAR humidity sensor, especially the new detection method of S11 parameter response for respiration monitoring.To solve the above-mentioned problems of the FBAR humidity sensor based on mass adsorption, our research group previously proposed a FBAR humidity sensor based on polyimide (PI) Young’s modulus modulation  rather t11 , we furty sensor . Results11 dual-parameter sensing was analyzed, designed, fabricated, and tested. The application of PI-based high-performance FBAR humidity sensor in real-time respiratory monitoring was performed. The responses of both the two parameters of resonant frequency and S11 to respiratory monitoring were experimented and compared. Both parameters were used to sense and monitor different rates of breathing, such as normal breathing, apnea, slow breathing, and fast breathing, as well as to sense the difference between oral and nasal breathing. Besides, a comparative analysis of the respiratory characteristic curves before and after exercise was carried out to predict the fitness of individual, especially for athletes. The respiration signals before and after water drinking were also well recorded and systematically analyzed for daily water intake warning. In order to prove the accuracy of the proposed PI-FBAR humidity sensor in human respiratory monitoring, respiratory rate test results of our prepared sensor operating in resonant frequency and S11 dual-parameter were compared with that measured by a clinical monitor.In this work, a PI-based FBAR humidity sensor operating in resonant frequency and reflection coefficient S11 is not clear, and it is tentatively presumed to be caused by the change in acoustic loss caused by water molecules. To explore the humidity sensing mechanism of S11 more systematically, Mason equivalent transmission line model [Though, it has been verified in our previous work  that thene model  is used Parameters in the above Mason model are defined as follows:The acoustic impedance As can be seen in Equation (2), the properties of PI-FBAR are related to the elasticity coefficient Other parameters in Mason model are as follows: Given the thickness and material parameters of each layer of PI-FBAR, as shown in 11 value of the resonator. In order to explore the modulation effect of attenuation factor 11, we simulated and analyzed the relationship between S11 and the change in 11 increases from −32 dB to −30 dB. Although the related expression cannot be given due to the complex relationship between the attenuation factor and humidity, the simulation results show that the increased PI viscoelasticity caused by the increase in humidity will lead to an increase in the value of S11.As we all know, PI is a porous polymer material, whose viscoelasticity will change with the change in humidity . As the 2 sacrifice and insulation layer, deposition and patterning of Pt bottom electrode, magnetron sputtering and patterning of ZnO piezoelectric film, deposition and patterning of Pt top electrode, spin coating and patterning PI layer, and etching SiO2 and Si from the back side. After the proposed sensor chip was prepared, the chip was fixed to the PCB board so that the sensor chip and the PCB board can be electrically interconnected by the gold wire ball welding technology, and then connected to the vector network analyzer through the SMA interface for subsequent testing.The designed PI-FBAR sensor chip was fabricated with the MEMS process described in our previous works ,25, inclThe preparation of PI film is crucial because it acts as both the supporting structure and the humidity sensitive structure. The polyamide acid solution used for the preparation of PI film is ZKPI-305IIE, purchased from Beijing POME Technology Co., LTD . The specific preparation process of PI is shown in 11 of the resonator. Specifically, as the ambient humidity increases, the PI absorbs moisture, which increases the resonant frequency and the S11 value. As the measured ambient humidity decreases, PI desorbs moisture, which reduces the resonant frequency and the S11 value.As discussed in our previous works ,25, due 2CO3 and KI. The proposed humidity sensor was inserted into a closed glass bottle and placed above the level of a saturated salt solution. A vector network analyzer  combined with the LabVIEW program was used to measure and record the real-time change in the resonant frequency and S11.The sensing performance test system of the PI-FBAR humidity sensor is shown in 11 responses of the respiratory rate with that measured by a clinical monitor , which obtains the breathing signal from the impedance change caused by human breathing.The diagram of the real-time human breathing monitoring system is shown in 11 from those reported in previous work may be due to the slight difference in the thickness of ZnO during magnetron sputtering and the difference in the surface properties of PI film.11 response, which may be caused by the fact that the frequency response requires a longer time to absorb and desorb humidity, and the frequency response is less stable than the S11 response. The baseline drift would be improved if the latency of the test in The prepared PI-FBAR humidity sensor was placed into different saturated salt solutions in equilibrium state with different relative humidity (RH) to test its humidity response characteristics. It should be pointed out that the sealed bottle with desiccant is regarded as 0%RH. Keep the humidity sensor in an airtight container with desiccant for 120 s, of which the RH is regarded as 0%, then quickly place it in a saturated salt solution with certain RH for 40 s, then place it in an airtight container with desiccant for 120 s, repeat this operation, until these different humidity environments of 11%, 33%, 50%, 75%, and 98% are repeated. Specifically, due to the large hysteresis from a high humidity environment of 98% to a dry environment of 0%, this process lasted for 3 min to make the sensor as pristine as possible. In order to test the continuous response stability of the humidity sensor, we conducted three rounds of experiments. The humidity response results are shown in 11, calculated by Equation (3), were shown in The humidity response sensitivity (S) of resonant frequency and S11 response sensitivity showed higher linear sensitivity at low humidity and lower linear sensitivity at high humidity. The reduced sensitivity in high humidity environment is mainly caused by the PI mass loading effect in high humidity environment, which reduced the frequency of the resonator, thereby offsetting the value of the frequency increase caused by the increase in PI’s Young’s modulus. For the lower relative humidity from 0% to 33%, the sensitivity of the resonant frequency and the S11 response are 56 ppm/RH and 964 ppm/RH, respectively, and for the higher relative humidity from 33% to 98%, the sensitivity of the resonance frequency and the S11 response are 15 ppm/RH and 570 ppm/RH. Although the sensitivities of both parameters are reduced in higher relative humidity environments, they are still sufficient for subsequent human respiration monitoring applications. Results showed that the sensitivities of S11 in both high and low humidity environments are several tens of times higher than those of resonant frequency.Both the resonant frequency and the S11 response have good repeatability, and the stability of S11 is even better than that of the resonant frequency response.Besides, in order to analyze the stability of the sensor more intuitively, we compared the response results of three rounds of experiments, as shown in 11 responses for 6 h in different humid environments . As shown in 11 response, respectively, these two responses showed that the proposed sensor possesses high stability with small errors.Apart from that, the sensor’s stability was tested by measuring the resonant frequency and S11 with periodic changes in humidity from 0 to 98% were shown in 11 response, the time of 63% and 90% complete adsorption response are 6 s and 15 s, respectively, and those of desorption response are 7 s and 19 s, respectively. For the resonant frequency response, the time of 63% and 90% complete adsorption response are 5 s and 12 s, respectively, and those of desorption response are 9 s and 26 s, respectively. These results showed that the resonant frequency response is faster than that of S11 in the process of moisture absorption, while the response of S11 is faster than that of the resonant frequency in the process of desorption. The humidity response performance of both parameters is sufficient for most humidity detection applications. In addition, study [The real-time responses of the resonant frequency and Sn, study  has showComparisons of the performance of our designed sensor in this work with some other piezoelectric acoustic resonant humidity sensors in previous literature are listed in 11 curves, shown in 11 during expiratory periods, while there was a decrease during the inspiratory periods. This can be attributed to the fact that a large amount of water vapor is brought in when exhaling, causing the humidity to rise, while most of the water vapor is taken away due to the air flow when inhaling, making the humidity decrease, which is consistent with the sensor’s frequency and S11 response of humidity as described above. The results shown in 11 parameters caused by deep breathing are greater than that of normal breathing, which may be attributed to the significantly large volume of air movement during the deep breathing process. Additionally, deep breathing is usually accompanied by a decrease in respiratory rate (RR). These significant differences between normal and deep breathing suggested the applicability of the fabricated PI-FBAR humidity sensor for identification and diagnosis of several health conditions such as asthma, tachypnoea, etc.Monitoring of different breathing conditions was performed on a healthy adult volunteer to study the feasibility of the PI-FBAR humidity sensor performance see . During 11 variation during oral breathing are greater than that of nasal breathing. The frequency shift of nearly 0.4 MHz and a change in S11 value nearly 0.2 dB were observed during the nasal breathing, whereas a frequency shift of nearly 0.6 MHz and a change in S11 value nearly 0.3 dB were observed during the oral breathing. The increase in the changes in frequency and S11 in case of oral breath is attributed to the large intake of air volume and subsequent increase in number of molecules interacting with the sensor as compared to that of the nasal breath. Furthermore, the presence of nasal mucosa creates filtered air which may also affect the overall humidity during the nasal breathing mode.Performance of the fabricated sensor under different breathing modes, such as nasal breathing and oral breathing, was also analyzed. As shown in 11 and frequency of the humidity sensor for nasal breathing with different respiration rates are demonstrated in The fabricated sensor was thereafter used for continuous inspection on respiration rate (RR). For normal adults, the normal breathing rate is 12–20 per minute, and breathing rates outside the normal range may indicate health problems. The response curves of S11 can efficiently distinguish between varying breathing rates, indicating their potential for real time health monitoring.The respiration rates for slow, normal, and fast breath modes observed in 11 or frequency change in every respiration state. In case of nasal breathing before vigorous exercise, as shown in 11 response are 16 per minute and nearly 0.15 dB, and those calculated from resonant frequency response are 16 per minute and nearly 0.32 MHz. However, in the case of nasal breathing after vigorous exercise, as shown in 11 response change to be 36 per minute and nearly 0.11 dB, and those calculated from resonant frequency response are 36 per minute and nearly 0.22 MHz.The respiration rate (RR) and depth of respiration (DR) before and after climbing six floors were also monitored and breathing index (BI) was calculated to estimate the fitness level of five individuals. As can be observed from The empirical metric, Breathing Index (BI), is defined as the ratio of respiration rate to the depth of respiration under light and vigorous exercises . In our 11 response were calculated to be approximately 1.55 (>1) and 1.65 (>1), respectively. Results (BI > 1) revealed that subject 2 exchanged a larger volume of air during climbing six floors than he did during rest state. The calculated BIs of the five subjects were shown in 11 can be used to efficiently predict the fitness of individual, especially for athletes.By using Equation (4), the BI of subject 2 at frequency response and S11 and resonant frequency increased after water intake, and then showed a tendency to decrease over time, indicating the process of water loss. Results proved that our sensors have the potential application in the medical field for detecting the loss of body fluids and daily water intake warning.As one of the indicators of personal health, daily water intake can also affect respiratory humidity. Respiration signals of the proposed PI-FBAR sensor were also recorded before and after water intake, and the dynamic response curves of nasal breathing were plotted in 11 parameters to different breathing modes and breathing states is better than that of resonant frequency, which is manifested in the smaller glitch of the waveform and more balanced amplitude, indicating that the S11 parameter is more suitable for respiration monitoring.In summary, our proposed humidity sensor can not only record the user’s respiration rate and respiration manner, but also predict the fitness and monitor the dehydration of individual, which is useful for patients’ clinical nursing. More notably, from the monitored signal curves, the response of S11 responses with that measured by the clinical monitor. The experimental comparison results are shown in 11 and resonant frequency response results with that of the clinical monitor, in the range of different respiration rates ranging from a few to three dozen, were 0.982 and 0.975, respectively. The highly correlated results with clinical monitor demonstrated the reliability of our fabricated sensor for respiratory monitoring.In order to further prove the accuracy of the proposed PI-FBAR humidity sensor in human respiratory monitoring, we compared the respiratory rate test results of the sensor’s resonant frequency and S11 and resonant frequency response results with that of the clinical monitor were also analysed by Bland–Altman method [11 and frequency response with that measured by clinical monitor were  and , respectively. The results showed that most of the differences fall within the 95% confidence interval. After analysing the original breathing signal, it can be seen that very few points with larger differences are due to the sudden change in the breathing rate. Different breathing rate extraction algorithms lead to inconsistency in the calculation results of the breathing rate. Anyway, results showed that both S11 and frequency response are in good agreement with clinical monitor, and the results measured by S11 had better consistency.In addition, the consistency of Sn method . Its bas11 dual-parameter was proposed and fabricated for real-time human respiration monitoring. The proposed PI-FBAR sensor operating in resonant frequency was governed by the modulation of the humidity on the Young’s modulus of PI, which is different from the conventional FBAR governed by mass loading effect, whereas the proposed PI-FBAR sensor operating in S11 was based on the modulation of the humidity on attenuation factor of PI layer. Humidity response test results showed that both resonant frequency and S11 dual parameters exhibit high sensitivity and stability, and particularly, the sensitivity of the S11 mode was dozens of times higher than that of the frequency. The prepared dual-parameter PI-FBAR, especially that operating in S11 mode, was proposed for the first time for human respiration monitoring. Results showed that both the frequency shift and reflection coefficient S11 variation can be used to sense different breathing conditions, such as normal breathing and deep breathing, normal breathing, slow breathing, apnea, and fast breathing by detecting respiration rate and depth of respiration. They can also be used for detection in different breathing modes, such as nasal breathing and mouth breathing. Experimental results also indicated that the proposed humidity sensor had potential applications in predicting the fitness of individual and in the medical field for detecting body fluids loss and daily water intake warning. The respiratory rate measured by our proposed PI-FBAR humidity sensor operating in frequency mode and S11 mode has a Pearson correlation of up to 0.975 and 0.982 with the respiratory rate measured by the clinical monitor, respectively. Bland–Altman method analysis results further showed that both S11 and frequency response are in good agreement with clinical monitor, and the results measured by S11 had better consistency. In summary, our proposed sensor combines the advantages of non-invasiveness, high sensitivity and high stability, and holds tremendous potential in human health monitoring.In this work, a polyimide-based film bulk acoustic resonator (PI-FBAR) humidity sensor operating in resonant frequency and reflection coefficient S