Dated molecular phylogenies are the basis for understanding species diversity and for linking changes in rates of diversification with historical events such as restructuring in developmental ...pathways, genome doubling, or dispersal onto a new continent. Valid fossil calibration points are essential to the accurate estimation of divergence dates, but for many groups of flowering plants fossil evidence is unavailable or limited. Arabidopsis thaliana, the primary genetic model in plant biology and the first plant to have its entire genome sequenced, belongs to one such group, the plant family Brassicaceae. Thus, the timing of A. thaliana evolution and the history of its genome have been controversial. We bring previously overlooked fossil evidence to bear on these questions and find the split between A. thaliana and Arabidopsis lyrata occurred about 13 Mya, and that the split between Arabidopsis and the Brassica complex (broccoli, cabbage, canola) occurred about 43 Mya. These estimates, which are two- to threefold older than previous estimates, indicate that gene, genomic, and developmental evolution occurred much more slowly than previously hypothesized and that Arabidopsis evolved during a period of warming rather than of cooling. We detected a 2- to 10-fold shift in species diversification rates on the branch uniting Brassicaceae with its sister families. The timing of this shift suggests a possible impact of the Cretaceous–Paleogene mass extinction on their radiation and that Brassicales codiversified with pierid butterflies that specialize on mustard-oil–producing plants.
To provide a snapshot of the profile of adults and youth with type 1 diabetes (T1D) in the United States and assessment of longitudinal changes in T1D management and clinical outcomes in the T1D ...Exchange registry.
Data on diabetes management and outcomes from 22,697 registry participants (age 1-93 years) were collected between 2016 and 2018 and compared with data collected in 2010-2012 for 25,529 registry participants.
Mean HbA1c in 2016-2018 increased from 65 mmol/mol at the age of 5 years to 78 mmol/mol between ages 15 and 18, with a decrease to 64 mmol/mol by age 28 and 58-63 mmol/mol beyond age 30. The American Diabetes Association (ADA) HbA1c goal of <58 mmol/mol for youth was achieved by only 17% and the goal of <53 mmol/mol for adults by only 21%. Mean HbA1c levels changed little between 2010-2012 and 2016-2018, except in adolescents who had a higher mean HbA1c in 2016-2018. Insulin pump use increased from 57% in 2010-2012 to 63% in 2016-2018. Continuous glucose monitoring (CGM) increased from 7% in 2010-2012 to 30% in 2016-2018, rising >10-fold in children <12 years old. HbA1c levels were lower in CGM users than nonusers. Severe hypoglycemia was most frequent in participants ≥50 years old and diabetic ketoacidosis was most common in adolescents and young adults. Racial differences were evident in use of pumps and CGM and HbA1c levels.
Data from the T1D Exchange registry demonstrate that only a minority of adults and youth with T1D in the United States achieve ADA goals for HbA1c.
Objective: A recent study identified that a cut-off score >5 on the Patient Health Questionnaire (PHQ-9) had greater sensitivity and specificity to detect DD in teens with T1D than the normative ...cut-off score. Still, limited provider training or capacity to intervene on a suicide screening item (item 9) leads some clinics to omit item 9. We examined the ideal cut-off score to detect DD in teens with T1D using the modified PHQ-8 screener, and if removing item 9 impacts sensitivity.
Methods: Teens (N=100; Mean age = 15.0 ± 1.7; 60% Male; 87% White; Mean HbA1c = 8.88 ± 1.8%) completed the PHQ-8 electronically. We used the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS DSM-5) depression module to determine if the teen met criteria for DD. We compared teens’ PHQ-8 cut-off scores (PHQ-8 ≥ 10) to KSADS results.
Results: Per KSADS, 15% of teens met criteria for current DD. The PHQ-8 demonstrated low sensitivity (.20) to detect DD using a normative cut-off score, but an adjusted cut-off score >5 increased sensitivity (.87) while maintaining good specificity (.80) (Table 1).
Conclusions: Using a lower cut-off score of >5 on the PHQ-8 can more reliably identify DD in teens with T1D and matches previous PHQ-9 sensitivity and specificity metrics. This suggests removing item 9 does not negatively impact DD screening accuracy, although clinics should consider alternative methods to screen for suicide risk.
Disclosure
S.R.Patton: None. A.Marker: None. R.Mcdonough: None. M.A.Clements: Consultant; Glooko, Inc., Research Support; Dexcom, Inc., Abbott Diabetes.
Adolescents and young adults with type 1 diabetes exhibit the worst glycemic control among individuals with type 1 diabetes across the lifespan. Although continuous glucose monitoring (CGM) has been ...shown to improve glycemic control in adults, its benefit in adolescents and young adults has not been demonstrated.
To determine the effect of CGM on glycemic control in adolescents and young adults with type 1 diabetes.
Randomized clinical trial conducted between January 2018 and May 2019 at 14 endocrinology practices in the US including 153 individuals aged 14 to 24 years with type 1 diabetes and screening hemoglobin A1c (HbA1c) of 7.5% to 10.9%.
Participants were randomized 1:1 to undergo CGM (CGM group; n = 74) or usual care using a blood glucose meter for glucose monitoring (blood glucose monitoring BGM group; n = 79).
The primary outcome was change in HbA1c from baseline to 26 weeks. There were 20 secondary outcomes, including additional HbA1c outcomes, CGM glucose metrics, and patient-reported outcomes with adjustment for multiple comparisons to control for the false discovery rate.
Among the 153 participants (mean SD age, 17 3 years; 76 50% were female; mean SD diabetes duration, 9 5 years), 142 (93%) completed the study. In the CGM group, 68% of participants used CGM at least 5 days per week in month 6. Mean HbA1c was 8.9% at baseline and 8.5% at 26 weeks in the CGM group and 8.9% at both baseline and 26 weeks in the BGM group (adjusted between-group difference, -0.37% 95% CI, -0.66% to -0.08%; P = .01). Of 20 prespecified secondary outcomes, there were statistically significant differences in 3 of 7 binary HbA1c outcomes, 8 of 9 CGM metrics, and 1 of 4 patient-reported outcomes. The most commonly reported adverse events in the CGM and BGM groups were severe hypoglycemia (3 participants with an event in the CGM group and 2 in the BGM group), hyperglycemia/ketosis (1 participant with an event in CGM group and 4 in the BGM group), and diabetic ketoacidosis (3 participants with an event in the CGM group and 1 in the BGM group).
Among adolescents and young adults with type 1 diabetes, continuous glucose monitoring compared with standard blood glucose monitoring resulted in a small but statistically significant improvement in glycemic control over 26 weeks. Further research is needed to understand the clinical importance of the findings.
ClinicalTrials.gov Identifier: NCT03263494.
We developed a machine learning model that predicts risk of declining engagement (churn) with an mHealth app (Glooko) that supports diabetes self-management. The model uses self-monitored blood ...glucose (SMBG), demographic, and app engagement data.
We selected 7134 PWD using meter and/or insulin pump devices who used the Glooko diabetes management app in a remote (outside of the clinic) setting between 1/1/2019-7/1/2019 (40,349 total weekly predictions). We trained a gradient boosting algorithm to predict risk of churn in the next 28 days.
We built features using data from the prior 28 days; features included outcomes (counts of glucose checks, hypo/hyperglycemia occurrences, mean blood glucose), app engagement (counts of app clicks and meter and/or insulin pump uploads, duration of sessions), and demographics (diabetes type, gender, age).
The training cohort had median age=22 years (IQR:11-49), 52% female, 60% type 1 diabetes (T1D). We performed out-of-sample validation using 4647 individuals (8646 total weekly predictions). The validation cohort had median age=20 years (IQR:11-49), 52% female, 60.5% T1D. The algorithm predicted individuals at risk of churning with a precision of 0.67 and a recall of 0.8. This correlates to sensitivity=80%, specificity=58%, and positive predictive value=67%.
The present model indicates that it is feasible to predict declining engagement with an mHealth app to support diabetes self-management. The ability to predict churn may help clinics design effective mHealth-based RPM programs. These predictions can allow clinicians to proactively reach out to PWDs at risk of program dropout. Future research should examine whether dropout from RPM programs predicts worsening diabetes-related outcomes.
Disclosure
S. Babikian: Employee; Self; Glooko, Inc. V. Singh: Employee; Self; Glooko, Inc. M.A. Clements: Consultant; Self; Glooko, Inc. Other Relationship; Self; Glooko, Inc.
Aim: Orchidaceae is the most species-rich angiosperm family and has one of the broadest distributions. Until now, the lack of a well-resolved phylogeny has prevented analyses of orchid historical ...biogeography. In this study, we use such a phylogeny to estimate the geographical spread of orchids, evaluate the importance of different regions in their diversification and assess the role of long-distance dispersal (LDD) in generating orchid diversity. Location: Global. Methods: Analyses use a phylogeny including species representing all five orchid subfamilies and almost all tribes and subtribes, calibrated against 17 angiosperm fossils. We estimated historical biogeography and assessed the importance of different regions for rates of speciation, extinction and net species diversification. We evaluated the impact of particular LDD events on orchid diversity by asking how many species evolved in the new range subsequent to those events. Results: Orchids appear to have arisen in Australia 112 Ma (95% higher probability distribution: 102.0—120.0 Ma), then spread to the Neotropics via Antarctica by 90 Ma (HPD: 79.7—99.5 Ma), when all three continents were in close contact and apostasioids split from the ancestor of all other orchids. Ancestors of vanilloids, cypripedioids and orchidoids+ epidendroids appear to have originated in the Neotropics 84—64 Ma. Repeated long- and short-distance dispersal occurred through orchid history: stochastic mapping identified a mean total of 74 LDD events or 0.8 Ma⁻¹. Across orchid history, Southeast Asia was the most important source and maximally accelerated net diversification; across epidendroids, the Neotropics maximally accelerated diversification. Main conclusions: Our analysis provides the first biogeographical history of the orchids, implicating Australia, the Neotropics and Antarctica in their origin. LDD and life in the Neotropics — especially the Andes — had profound effects on their spread and diversification; > 97% of all orchid species are restricted to individual continents.
Orchids are the most diverse family of angiosperms, with over 25 000 species, more than mammals, birds and reptiles combined. Tests of hypotheses to account for such diversity have been stymied by ...the lack of a fully resolved broad-scale phylogeny. Here, we provide such a phylogeny, based on 75 chloroplast genes for 39 species representing all orchid subfamilies and 16 of 17 tribes, time-calibrated against 17 angiosperm fossils. A supermatrix analysis places an additional 144 species based on three plastid genes. Orchids appear to have arisen roughly 112 million years ago (Mya); the subfamilies Orchidoideae and Epidendroideae diverged from each other at the end of the Cretaceous; and the eight tribes and three previously unplaced subtribes of the upper epidendroids diverged rapidly from each other between 37.9 and 30.8 Mya. Orchids appear to have undergone one significant acceleration of net species diversification in the orchidoids, and two accelerations and one deceleration in the upper epidendroids. Consistent with theory, such accelerations were correlated with the evolution of pollinia, the epiphytic habit, CAM photosynthesis, tropical distribution (especially in extensive cordilleras), and pollination via Lepidoptera or euglossine bees. Deceit pollination appears to have elevated the number of orchid species by one-half but not via acceleration of the rate of net diversification. The highest rate of net species diversification within the orchids (0.382 sp sp−1 My−1) is 6.8 times that at the Asparagales crown.
Purpose
Routine evaluation of basic surgical skills in medical schools requires considerable time and effort from supervising faculty. For each surgical trainee, a supervisor has to observe the ...trainees in person. Alternatively, supervisors may use training videos, which reduces some of the logistical overhead. All these approaches however are still incredibly time consuming and involve human bias. In this paper, we present an automated system for surgical skills assessment by analyzing video data of surgical activities.
Method
We compare different techniques for video-based surgical skill evaluation. We use techniques that capture the motion information at a coarser granularity using symbols or words, extract motion dynamics using textural patterns in a frame kernel matrix, and analyze fine-grained motion information using frequency analysis.
Results
We were successfully able to classify surgeons into different skill levels with high accuracy. Our results indicate that fine-grained analysis of motion dynamics via frequency analysis is most effective in capturing the skill relevant information in surgical videos.
Conclusion
Our evaluations show that frequency features perform better than motion texture features, which in-turn perform better than symbol-/word-based features. Put succinctly, skill classification accuracy is positively correlated with motion granularity as demonstrated by our results on two challenging video datasets.
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