Iron Deficiency among School-Aged Adolescents in Hong Kong: Prevalence, Predictors, and Effects on Health-Related Quality of Life.

Iron deficiency (ID) is a prevalent nutritional deficiency affecting children/adolescents worldwide. We reported (1) the prevalence of ID and ID with anemia (IDA) among Chinese school-aged adolescents, (2) clinical and dietary predictors of iron status, and (3) its impact on health-related qualities of life (HRQoL). This cross-sectional study recruited 183 boys and 340 girls (mean age = 17.55) from 16 schools in Hong Kong. ID is defined as serum ferritin <15 µg/L. The participants reported their dietary habits, menstrual patterns (girls), and HRQoL using structured questionnaires. The overall prevalence of ID was 11.1%. None of the boys had ID or IDA. Among girls, the rate of ID was 17.1% and IDA was 10.9%. One-third (36.3%) reported a regular habit of skipping ≥1 meal/day. Lower ferritin was found in adolescents who skipped meals (Est = -35.1, p = 0.017). Lower ferritin is correlated with poorer school functioning (Est = 0.81, p = 0.045) and fatigue (Est = 0.92, p = 0.016). Skipping meals is associated with poorer physical (p = 0.0017) and school functioning (p = 0.027). To conclude, 1 in 10 school-aged adolescents in Hong Kong are iron-deficient. The ID rate in girls (17.1%) is similar to that in other industrialized countries (5.2-16.6%). Future work should promote awareness on the potential health consequences of poor dietary habits on ID and the well-being of adolescents.

Acceptability of a parent-focused program for physical literacy development among parents and children during the COVID-19 pandemic: A qualitative study.

Background: A 3-month parent education program was designed and implemented in Hong Kong to improve physical literacy (PL) among primary school children and their parents during the COVID-19 pandemic. This study aims to probe into the acceptability of the intervention from parental perspectives, providing more insights for future implementation. Methods: Following the 3-month parent-focused PL program, 16 parents (mean age = 43.73 years, 15 mothers) were recruited to participate in semi-structured individual interviews in June 2021. Interviews were analyzed using thematic analysis in NVivo 12. Two coders analyzed interview transcripts deductively based on the interview guide and social cognitive theory (SCT). Results: Three themes were identified that captured the acceptability of the program: (1) Addressing needs through appropriate delivery enhances acceptability of intervention; (2) Positive behavioral and psychological changes to families; (3) Appropriate support of environmental factors can enhance the sustainability of program effects. The high levels of acceptability were attributable to the fact that parents were able to learn and be a gatekeeper to impact their children positively. Moreover, the design and contents of the program were appropriate for the participating parents because the program provided adequate learning resources and interactive learning support without being overly rigid, and the online learning mode was feasible and convenient. Consequent to their participation in the program, parents expressed that they became more aware of the importance of PL, established physical activity routines with their children, and modified their parenting styles which resulted in improved parent-child relationships. Conclusions: The current study provided evidence that engaging parents in the intervention was feasible and acceptable approach in supporting both parents and children to establish physically active routines in the family setting. The insights gained regarding the appropriateness and acceptability of the program in this specific context may be used to inform the design, implementation and sustainability of other parent-focused PL programs.

Tuning in to kids: A randomized controlled trial of an emotion coaching parenting program for Chinese parents in Hong Kong.

Tuning in to Kids (TIK) is a parenting program that focuses on emotion coaching and is evidenced to be effective in Western populations. This study used a randomized controlled trial to examine the intervention effects of TIK on Chinese parents of low to middle socioeconomic status in Hong Kong. One hundred four parents (99 mothers and five fathers; Mage in years = 37.92) of preschoolers aged 3-6 years were randomly assigned to the experimental (n = 54) or waitlist control group (n = 50). Parent and child outcomes were assessed at baseline (Time 1), immediately after the 6-week intervention (Time 2), and 6 weeks postintervention (Time 3), using the Alabama Parenting Questionnaire, Coping with Children's Negative Emotions Scale, Parenting Stress Index-Short Form, and Emotion Regulation Checklist. The experimental group reported significant reductions in punitive parenting and parenting stress at Time 2, and these effects were maintained at Time 3. Delayed improvements in parents' use of expressive encouragement and children's emotion lability/negativity were observed at Time 3 in the experimental group. The immediate intervention effects were replicated in the waitlist control group at Time 3 after they attended the training. This study represented one of the few randomized controlled trials of TIK conducted in a non-Western sample. Our results corroborated the findings of prior studies of TIK and provided preliminary support for its effectiveness across different cultural contexts. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effectiveness of Online Mindfulness-Based Interventions on Psychological Distress and the Mediating Role of Emotion Regulation.

Online mindfulness-based intervention as a feasible and acceptable approach has received mounting attention in recent years, yet more evidence is needed to demonstrate its effectiveness. The primary objective of this study was to examine the effects of online mindfulness-based programs on psychological distress (depression and anxiety). The randomized controlled intervention design consisted of four conditions: group mindfulness-based intervention (GMBI), self-direct mindfulness-based intervention (SDMBI), discussion group (DG) and blank control group (BCG). The program lasted 8 weeks and a total of 76 participants completed the pre- and post-test. Results showed that participants in GMBI and SDMBI had significant pre- and post-test differences on mindfulness, emotion regulation difficulties, and psychological distress, with medium to large effect sizes. In addition, ANCOVA results indicated significant effects of group membership on post-test scores of mindfulness, depression and anxiety when controlling the pretest scores, with medium to large effect sizes. The GMBI appeared to exert the greatest effects on outcome variables in comparison with other groups. In addition, changes in emotion regulation difficulties across groups could mediate the relationship between changes in mindfulness dimensions (Observing and Describing) and changes in psychological distress across groups. These results provided encouraging evidence for the effectiveness of online mindfulness-based interventions in reducing psychological distress, and the possible mediating role of emotion regulation, while also underlining the importance of group discussion in online mindfulness-based interventions.

Dual-opposite multi-walled carbon nanotube modified carbon fiber microelectrode for microfluidic chip-capillary electrophoresis determination of methyl parathion metabolites in human urine.

Methyl parathion (MP) is a highly toxic organophosphate and its exposure may lead to substantial adverse effects to human health. The existence of 4-nitrophenol (4-NP) in the form of free phenol, glucuronide (4-NP-G) or as a sulfate ester (4-NP-S) can be used as biomarkers to assess the duration and extent of MP exposure. In this work, a MC-CE device incorporating post-CE amperometric detection using multi-walled carbon nanotubes (MWNTs) modified carbon fiber microelectrode (CFME) was fabricated and assessed for simultaneous determination of 4-NP, 4-NP-G, and 4-NP-S in human urine. The detection sensitivity and stability was greatly enhanced by the modification of MWNTs. The capability of the MC-CE device with dual MWNTs modified CFME for detecting impurity was assessed and reliability established by high recoveries from 95 to 97% for spiked MP biomarkers. The method developed is shown to provide a simple, sensitive, and reliable means for monitoring 4-NP, 4-NP-G, and 4-NP-S in human urine.

Contiguous gene deletion of chromosome 2p16.3-p21 as a cause of Lynch syndrome.

Lynch syndrome is an autosomal dominant condition caused by pathogenic mutations in the DNA mismatch repair (MMR) genes. Although commonly associated with clinical features such as intellectual disability and congenital anomalies, contiguous gene deletions may also result in cancer predisposition syndromes. We report on a 52-year-old male with Lynch syndrome caused by deletion of chromosome 2p16.3-p21. The patient had intellectual disability and presented with a prostatic adenocarcinoma with an incidentally identified synchronous sigmoid adenocarcinoma that exhibited deficient MMR with an absence of MSH2 and MSH6 protein expression. Family history was unrevealing. Physical exam revealed short stature, brachycephaly with a narrow forehead and short philtrum, brachydactyly of the hands, palmar transverse crease, broad and small feet with hyperpigmentation of the soles. The patient underwent total colectomy with ileorectal anastomosis for a pT3N1 sigmoid adenocarcinoma. Germline genetic testing of the MSH2, MSH6, and EPCAM genes revealed full gene deletions. SNP-array based DNA copy number analysis identified a deletion of 4.8 Mb at 2p16.3-p21. In addition to the three Lynch syndrome associated genes, the deleted chromosomal section encompassed genes including NRXN1, CRIPT, CALM2, FBXO11, LHCGR, MCFD2, TTC7A, EPAS1, PRKCE, and 15 others. Contiguous gene deletions have been described in other inherited cancer predisposition syndromes, such as Familial Adenomatous Polyposis. Our report and review of the literature suggests that contiguous gene deletion within the 2p16-p21 chromosomal region is a rare cause of Lynch syndrome, but presents with distinct phenotypic features, highlighting the need for recognition and awareness of this syndromic entity.

Rationale and design of the cardiorespiratory fitness and hospitalization events in armed forces study in Eastern Taiwan.

AIM: To investigate the association between cardiorespiratory fitness and hospitalization events in a cohort of large voluntary arm forces in Taiwan. METHODS: The cardiorespiratory fitness and hospitalization events in armed forces (CHIEF) is a retrospective cohort consisting of more than 4000 professional military members aged 18-50 years in Eastern Taiwan. All participants received history taking, physical examination, chest radiography, 12-lead electrocardiography, blood tests for cell counts and fasting glucose, lipid profiles, uric acid, renal function and liver function in the Hualien Armed Forces General Hospital during 2014. In addition, participants were required to undergo two indoor resistant exercise tests including 2-min push-up and 2-min sit-up, both scored by infrared sensing, and one outdoor endurance 3000-m none weight-bearing running test, the main indicator of cardiorespiratory fitness in the Military Physical Training and Testing Center in Eastern Taiwan in 2014. RESULTS: Hospitalization events for cardiovascular disease, acute kidney injury, rhabdomyolysis, severe infectious disease, acute psychiatric illness, diabetes, orthopedic surgery and mortality will be identified in the National Insurance Research Database for 10 years. CONCLUSION: CHIEF will be among the largest Eastern Asian armed forces cohort, in which physical status was strictly evaluated to follow up the hospitalization events for severe illness.

Socioeconomic Gradient in Childhood Obesity and Hypertension: A Multilevel Population-Based Study in a Chinese Community.

BACKGROUND: This study aims to assess evidence for any socioeconomic gradients in childhood obesity and hypertension in a population-representative sample in Hong Kong, China. METHODS: The data of a stratified random sampled growth survey collected in 2005-2006 was matched with a population by-census. Obesity was defined using the International Obesity Task Force standard and hypertension was defined using the Hong Kong norm table. Family socioeconomic status (SES) was measured by maternal education level. Neighbourhood SES was measured by median household income of the neighbourhood. Multilevel Poisson regression models with robust standard error were used to test the association. Body mass indices of children's parents were included as potential confounders. Intra-school/neighbourhood correlations were adjusted using random factors. RESULTS: Totally 14842 children (age 6-19 years) included in the analysis, in which 16.6% of them were overweight or obese. Children whose mother only completed secondary school or below had higher risk of childhood obesity (RR 1.41, 95% CI 1.13-1.76, p = 0.003) and hypertension (RR 1.18, 95% CI 1.01-1.36, p = 0.03). Meanwhile, children in the lowest neighbourhood SES group had higher risk of childhood underweight (RR 1.61, 95% CI 1.04-2.49, p = 0.03), overweight (RR 1.35, 95% CI 1.05-1.72, p = 0.02), and obesity (RR 2.07, 95% CI 1.11-3.88, p = 0.02). CONCLUSIONS: Socioeconomic gradient in childhood obesity and hypertension existed in Hong Kong, one of the most developed cities in China. These results have implications for policymakers and public health experts and highlight the need to monitor trends in other parts of China.

PKLR promotes colorectal cancer liver colonization through induction of glutathione synthesis.

Colorectal cancer metastasis to the liver is a major cause of cancer-related death; however, the genes and pathways that govern this metastatic colonization event remain poorly characterized. Here, using a large-scale in vivo RNAi screen, we identified liver and red blood cell pyruvate kinase (PKLR) as a driver of metastatic liver colonization. PKLR expression was increased in liver metastases as well as in primary colorectal tumors of patients with metastatic disease. Evaluation of a murine liver colonization model revealed that PKLR promotes cell survival in the tumor core during conditions of high cell density and oxygen deprivation by increasing glutathione, the primary endogenous antioxidant. PKLR negatively regulated the glycolytic activity of PKM2, the major pyruvate kinase isoenzyme known to regulate cellular glutathione levels. Glutathione is critical for metastasis, and we determined that the rate-limiting enzyme of glutathione synthesis, GCLC, becomes overexpressed in patient liver metastases, promotes cell survival under hypoxic and cell-dense conditions, and mediates metastatic liver colonization. RNAi-mediated inhibition of glutathione synthesis impaired survival of multiple colon cancer cell lines, and pharmacological targeting of this metabolic pathway reduced colonization in a primary patient-derived xenograft model. Our findings highlight the impact of metabolic reprogramming within the niche as metastases progress and suggest clinical potential for targeting this pathway in colorectal cancer.

Determination of taurine in human tear fluid by capillary electrophoresis with indirect amperometric detection based on electrogenerated bromine.

A new method for the determination of taurine was developed based on indirect amperometric detection after capillary electrophoresis. A serial dual-electrode detector comprising an on column Pt film electrode (upstream electrode) and an end column Pt microdisk electrode (downstream electrode) was utilized to conduct the indirect amperometric detection. Bromide is oxidized to bromine at upstream electrode and reduced back to bromide at downstream electrode. Since taurine can react with bromine quantitatively and rapidly, its concentration can therefore be determined by the decrease of the current for bromine reduction at the downstream electrode. Principal experimental parameters governing the analytical performance were investigated and optimized. Under the optimal conditions, taurine can be baseline separated from interfering amino acids and the detection limit of 0.18 µM was obtained with a linear correlation coefficient of 0.999 over the concentration range of 0.5-60 µM. The developed method has been successfully applied in the determination of taurine in human tear fluid. The taurine level obtained was in good agreement with previous reports and recoveries for taurine spiked ranged from 92-95% with relative standard deviations within 4.6%, demonstrating the reliability of the developed method in the determination of taurine in human tear fluid.

Multidimensional microchip-capillary electrophoresis device for determination of functional proteins in infant milk formula.

Functional proteins have been found in infant milk formula as supplements, added by an increasing number of manufacturers. Their supplementations are expected to be controlled and monitored. Here, we describe a microchip-integrated CE method for the determination of these low levels of functional proteins in a protein-rich sample matrix. On-chip isoelectric focusing (IEF) is used to separate high-abundance proteins from low-abundance proteins instead of using some complicated time-consuming protein purification process. After that, transient isotachophoresis hyphenated capillary zone electrophoresis (t-ITP-CZE) can preconcentrate, separate, and analyze transferred functional proteins in the embedded capillary under UV detection.

Extracellular metabolic energetics can promote cancer progression.

Colorectal cancer primarily metastasizes to the liver and globally kills over 600,000 people annually. By functionally screening 661 microRNAs (miRNAs) in parallel during liver colonization, we have identified miR-551a and miR-483 as robust endogenous suppressors of liver colonization and metastasis. These miRNAs convergently target creatine kinase, brain-type (CKB), which phosphorylates the metabolite creatine, to generate phosphocreatine. CKB is released into the extracellular space by metastatic cells encountering hepatic hypoxia and catalyzes production of phosphocreatine, which is imported through the SLC6A8 transporter and used to generate ATP­fueling metastatic survival. Combinatorial therapeutic viral delivery of miR-551a and miR-483-5p through single-dose adeno-associated viral (AAV) delivery significantly suppressed colon cancer metastasis, as did CKB inhibition with a small-molecule inhibitor. Importantly, human liver metastases express higher CKB and SLC6A8 levels and reduced miR-551a/miR-483 levels relative to primary tumors. We identify the extracellular space as an important compartment for malignant energetic catalysis and therapeutic targeting.

A serial dual-electrode detector based on electrogenerated bromine for capillary electrophoresis.

A new serial dual-electrode detector for CE has been designed and fabricated for postcolumn reaction detection based on electrogenerated bromine. A coaxial postcolumn reactor was employed to introduce bromide reagent and facilitate the fabrication of upstream generation electrode by simply sputtering Pt film onto the outer surface of the separation capillary. Bromide introduced could be efficiently converted to bromine at this Pt film electrode and subsequently detected by the downstream Pt microdisk detection electrode. Analytes that react with bromine could be determined by the decrease of bromine reduction current at the downstream electrode resulting from the reaction between analytes and bromine. The effects of serial dual-electrode detector working conditions including electrode potentials, bromide flow rate, and bromide concentration on analytical performance were investigated using glutathione (GSH) and glutathione disulfide (GSSG) as test analytes. Under the optimal conditions, detection limits down to 0.16 µM for GSH and 0.14 µM for GSSG (S/N = 3) as well as linear working ranges of two orders of magnitude for GSH and GSSG were achieved. Furthermore, the separation efficiency obtained by our dual-electrode detector design was greatly improved compared with previous reported design. The developed method has been successfully applied to determine the GSH and GSSG impurity in commercial GSH supplement.

Reliability and validity of Alternate Step Test times in subjects with chronic stroke.

OBJECTIVE: (i) To investigate the intra-rater, inter-rater and test-retest reliability and minimal detectable change of the Alternate Step Test (AST) when assessing people with chronic stroke. (ii) To quantify the correlation between AST times and stroke-specific impairments. DESIGN: Cross-sectional study. SETTING: University-based rehabilitation centre. PARTICIPANTS: A convenience sample of 86 participants: 45 with chronic stroke, and 41 healthy elderly subjects. METHODS: The AST was administered along with the Fugl-Meyer Lower Extremity Assessment (FMA-LE), the Five Times Sit-To-Stand Test (FTSTS), limits of stability (LOS) measurements, Berg Balance Scale (BBS) scores, Chinese-translated Activities-specific Balance Confidence Scale (ABC-C) ratings, and the Timed "Up and Go" test (TUG). RESULTS: Excellent intra-rater, inter-rater and test-retest reliability were found, with a minimal detectable change of 3.26 s. AST times were significantly associated with FMA-LE assessment, FTSTS times, LOS in the forward and backward directions and to the affected side, BBS ratings and TUG times. CONCLUSION: AST time is a reliable assessment tool that correlates with different stroke-specific impairments in people with chronic stroke.

Simultaneous determination of gaseous and particulate carbonyls in air by coupling micellar electrokinetic capillary chromatography with molecular imprinting solid-phase extraction.

A novel method coupling molecular imprinting solid-phase extraction (MISPE) and micellar electrokinetic capillary chromatography (MEKC) was developed to enable the hourly determination of low level of ambient carbonyls, and study their partition between gaseous phase and particulate phase. With 2,4-dinitroaniline (DNAN) as dummy imprinting template, the unreacted 2,4-Dinitrophenylhydrazine (DNPH) in sampling solution could be removed effectively using MISPE, and an average recovery of 97±5.3% (n=5) for the carbonyl-DNPH derivatives was achieved. Owing to the high enrichment due to sample clean-up, and the improvement of MEKC separation efficiency, many low abundant carbonyls could be detected by hourly in the field study.

Assessment of adulteration of soybean proteins in dairy products by 2D microchip-CE device.

To determine the adulteration of soybean proteins in dairy product, a microchip-CE device was developed to isolate selected fraction of soybean and milk proteins in pI range from 5.5 ∼ 7.0 by 1D IEF, followed by ITP/CZE in the embedded capillary for preconcentration, separation and UV detection at 280 nm. Compared to IEF-CZE without ITP preconcentration, the enhancement factor (EF) in detection of soybean proteins was 20 times. Adulteration of 0.1% soybean protein in total dairy proteins can be detected in less than 10 min.

Myopia prevention, near work, and visual acuity of college students: integrating the theory of planned behavior and self-determination theory.

There has been little research examining the psychological antecedents of safety-oriented behavior aimed at reducing myopia risk. This study utilizes self-determination theory (SDT) and the theory of planned behavior (TPB) to understand the role of motivational and social-cognitive factors on individuals' near-work behavior. Adopting a prospective design, undergraduate students (n = 107) completed an initial questionnaire based on SDT in week 1, a second questionnaire containing measures of TPB variables in week 2, and objective measures of reading distance and visual acuity in week 6. The data were analyzed by variance-based structural equation modeling. The results showed that perceived autonomy support and autonomous motivation from SDT significantly predicted attitude, subjective norm, and perceived behavioral control from the TPB. These social-cognitive factors were significantly associated with intention and intention significantly predicted reading distance. The relationships in the model held when controlling for visual acuity. In conclusion, the integrated model of SDT and the TPB may help explain myopia-preventive behaviors.

Microfluidic chip capillary electrophoresis coupled with electrochemiluminescence for enantioseparation of racemic drugs using central composite design optimization.

Optimization based on central composite design (CCD) for enantioseparation of anisodamine (AN), atenolol (AT), and metoprolol (ME) in human urine was developed using a microfluidic chip-CE device. Coupling the flexible and wide working range of microfluidic chip-CE device to CCD for chiral separation of AN, AT, and ME in human urine, a total of 15 experiments is needed for the optimization procedure as compared to 75 experiments using the normal one variable at a time optimization. The optimum conditions obtained are found to be more robust as shown by the curvature effects of the interaction factors. The developed microfluidic chip-CE-ECL system with adjustable dilution ratios has been validated by satisfactory recoveries (89.5-99% for six enanotiomers) in urine sample analysis. The working range (0.3-600 µM), repeatability (3.1-4.9% RSD for peak height and 4.0-5.2% RSD for peak area), and detection limit (0.3-0.6 µM) of the method developed are found to meet the requirements for bedside monitoring of AN, AT, and ME in patients under critical conditions. In summary, the hyphenation of CCD with the microfluidic chip-CE device is shown to offer a rapid means for optimizing the working conditions on simultaneous separation of three racemic drugs using the microfluidic chip-CE device developed.

Multi-dimension microchip-capillary electrophoresis device for determination of functional proteins in infant milk formula.

To improve resolution of important minor proteins and eliminate time-consuming precipitation of major protein with associated analyte co-precipitation risk, a multi-dimension strategy is adopted in the 2D microchip-CE device to isolate major proteins on-chip, enrich minor proteins in capillary before their separation in CE for UV quantitation. A standard fluorescent protein mixture containing FITC-BSA, myoglobin and cytochrome as specific pI markers has prepared to demonstrate capability of the device to fractionate minor proteins by IEF. The results using a standard protein mixture with profile resembling infant milk formula show a complete isolation of high abundance proteins by a 2-min 1D IEF run. The subsequent t-ITP/CZE run by on-chip high voltage switching delivers a high stacking ratio, realizing 60 folds enrichment of isolated protein fractions. All five important functional proteins (LF, IgG, α-LA, ß-LgA and ß-LgB) known to fortify infant milk formula are isolated and determined using two consecutive t-ITP-CZE runs within a 18-min total assay time, a significant saving compared to several hours conventional pretreatment. For a 100g infant milk formula sample, working ranges of 20-8000mg, repeatability 3.8-5.3% and detection limits 2.3-10mg have been achieved to meet government regulations. Method reliability is established by 100% recoveries and agreeable results within expected ranges and labeled values. The capability of the device for field operation, rapid assay with quick results, label-free universal detection, simple operation by aqueous dissolution before injection, and the demanding matching in 2D separation based on isolated fractions at specified pI ranges, closely matched migration time and baseline-resolved peak shape makes the device a general tool to detect unknown proteins and determine known minor proteins in protein-rich samples with interfering constituents.

Repeatability and reproducibility of ultrasonographic measurement of carotid intima thickness.

PURPOSE: To evaluate the repeatability and reproducibility of intima thickness (IT) measurements at different sites along the common carotid artery and compare with intima-media thickness (IMT) measurements. METHODS: Ultrasound examinations of common carotid artery were performed in 30 healthy subjects and 20 patients with diabetes mellitus. Carotid IT and IMT were measured at 10 mm, 13 mm, and 16 mm upstream from the carotid bulb. Each subject was scanned by three operators to evaluate inter-operator reproducibility. Each operator scanned the subjects twice to evaluate intra-operator repeatability. Inter-equipment reproducibility of the measurements was evaluated. RESULTS: The inter-operator reproducibility for measuring carotid IT at the three sites was 81.5%, 81.9% and 69.1%, respectively, slightly lower than carotid IMT measurement (89.7%, 86.5%, 75.2%, respectively). The intra-operator repeatability for carotid IT measurement at the three sites ranged 76.9-89.5%, 67.4-90.3%, and 55.2-70.5%, respectively, and was lower than for IMT measurement (86.5-96.9%, 87.6-95.7%, 79.9-86.5%, respectively). The inter-equipment reproducibility of IMT (75.7-86.6%) was slightly better than for IT measurement (71.4-75.9%). CONCLUSIONS: Ultrasonographic measurement of carotid IT is repeatable and reproducible, although not as good as IMT. Measurements preformed 10 mm to 13 mm upstream from the carotid bulb yield more repeatable and reproducible results.