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Prevalence of, and factors associated with, diabetes mellitus in people with severe mental illness attending a multidisciplinary, outpatient cardiometabolic health assessment service
http://orcid.org/0000-0003-2118-7081Tim Lambert1,2,
Tim Middleton3,
Roger Chen4,5,
http://orcid.org/0000-0003-3521-3391Premala Sureshkumar1
1Concord Medical School, The University of Sydney, Sydney, New South Wales, Australia
2Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP), Concord Repatriation General Hospital, Concord, New South Wales, Australia
3Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
4Diabetes and Endocrinology, The University of Sydney, Sydney, New South Wales, Australia
5St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
Correspondence to Professor Tim Lambert; tim.lambert{at}sydney.edu.au
Introduction Evaluate the prevalence of, and factors associated with, diabetes in people with severe mental illness (SMI) attending the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) tertiary referral clinics.
Research design and methods Adult patients attending an initial ccCHiP clinic consultation (2014–2019) were studied. Diabetes was defined by an hemoglobin A1c of ≥6.5%, fasting blood glucose of ≥7.0 mmol/L, or a self-reported diagnosis of diabetes and prescription of antihyperglycemic medication.
Results Over 5 years, 1402 individuals attended a baseline consultation. Mean age of 43.9±12.8 years, 63.1% male and 63.5% had a diagnosis of schizophrenia. Prevalence of diabetes was 23.0% (n=322); an additional 19.5% fulfilled criteria for pre-diabetes. Of those with diabetes, 15.8% were newly diagnosed. Of those with pre-existing diabetes, 84.5% were receiving treatment with antihyperglycemic medication. Over 94% of individuals with diabetes had dyslipidemia; half were current smokers; and 46.4% reported sedentary behavior. On multivariate analysis, diabetes was associated with older age, Aboriginal, Indian or Middle Eastern maternal ethnicity, elevated waist-to-height ratio, family history of diabetes and use of antipsychotic medication.
Conclusion Prevalence of diabetes mellitus in this multiethnic cohort with SMI is significantly higher than the Australian population. Targeted interventions via an assertive integrated approach are required to optimize cardiometabolic health in this population.
Internationally, the risk of diabetes in people with severe mental illness (SMI) has been reported to exceed threefold that of the general population. While diabetes is undoubtedly a common comorbidity for Australians living with SMI, an accurate estimate of the prevalence of diabetes in Australians with SMI is yet to be firmly established.
Prevalence of diabetes mellitus in this multiethnic cohort of people with SMI is significantly higher than the background Australian population, especially in younger people. New diabetes was detected in 15.8% of the cohort.
Our finding of new diabetes in a multidisciplinary clinic setting provides support for more comprehensive screening in this high-risk population. Moreover, it raises the need for early intervention with a focus on younger people and in the subgroup of people with pre-diabetes as a preventative measure in reducing the risk of diabetes in this vulnerable population.
Diabetes remains one of the most common chronic health conditions1 and is associated with high levels of morbidity and premature mortality.2 3 The Australian Bureau of Statistics 2017–2018 National Health Survey estimated the prevalence of self-reported diabetes in the general Australian population to be 4.9%4 5; a further 3.1% of the Australian population has been estimated to have pre-diabetes.6
People with severe mental illness (SMI) are known to be at increased risk of diabetes.7 8 Those with SMI face significant medical and psychosocial challenges, and these undoubtedly contribute to an increased risk of diabetes. Chronic treatment with antipsychotic and other psychotropic medications is frequently associated with significant weight gain. Overweight and obesity are associated with increased insulin resistance and increased risk of dysglycemia. People with SMI face financial constraints that significantly restrict dietary choices. In addition, many people with SMI struggle to maintain adequate levels of physical activity with a significant proportion of this cohort leading sedentary lives.
Research has shown that individuals with SMI have excess mortality compared with the general population due to the development of premature chronic physical and medical conditions.8 There are reports that people with schizophrenia or bipolar disorder and diabetes have a higher mortality rate than those with no diabetes9 and those with SMI only.10 In a small Australian study, the combination of schizophrenia and diabetes increased the mortality rate by sixfold compared with that seen in people with neither condition.11 A large Danish registry-based study reported that the cumulative risk of death was 15.0% at 7 years post diagnosis of diabetes for the cohort of people <50 years of age with both SMI and diabetes.12 Similarly, in a British register-based study, Vinogradova et al found that 23.1% of people with SMI and diabetes died within 5 years of follow-up.9
Despite this knowledge, the screening and diagnosis of diabetes in this population remains poor due to limited access to care, fragmentation of care delivery and patient-related factors. It has been estimated that 70% of people prescribed second-generation antipsychotic pharmacotherapy remain unscreened for diabetes.13 Those with schizophrenia have a greater risk of acquiring acute and macrovascular complications14 of diabetes and an estimated 74% greater risk of requiring a hospital admission for hypoglycemia/hyperglycemia compared with those without schizophrenia.15
Internationally, the prevalence of diabetes in people with SMI has been reported to be two to three times higher than that in the general population without SMI.16 However, rigorous studies examining prevalence of diabetes in the setting of SMI in Australia are scarce. The self-reported prevalence of diabetes in the 2010 Australian Survey of High Impact Psychosis was 20%.17 Previous studies conducted within a number of Australian mental health services determined the combined prevalence of impaired fasting glucose and diabetes (diagnosed on the basis of elevated fasting glucose) in the SMI population to be >30%.18 19
A more comprehensive understanding of the diabetes burden in the Australian SMI population is clearly required. The primary aim of our study was to determine the prevalence of diabetes in this high-risk population using more comprehensive screening criteria for detecting diabetes and compare this to the general Australian population. The secondary aim was to investigate the factors associated with the diabetes status in these patients. This knowledge will help to facilitate more appropriate allocation of resources and thus provide an opportunity to improve early treatment and the holistic management of people with SMI.
The study population included adults (aged 18–65 years) with SMI who attended a baseline visit to the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) clinics between May 2014 and December 2019. The ccCHiP clinics are located within the Sydney Local Health District New South Wales, Australia, which services a catchment area of approximately 700 000 residents. ccCHiP provides a multidisciplinary, consultative service for patients with SMI, and referrals are received from local community mental health centers and local general practitioners. The service runs on an integrative health model with input from a psychiatrist, endocrinologist, cardiologist, dietitian, exercise physiologist, sleep clinician, nurse and oral health team.20 It is a one-stop shop where all clinicians are seen by the patient in a single session.
Diagnostic criteria used to classify diabetes mellitus and pre-diabetes in the ccCHiP clinic
For the purpose of this study, a hierarchical approach (table 1) was used to determine type 2 diabetes status (patients with type 1 diabetes are not seen in the clinic). If an individual presented with a hemoglobin A1c (HbA1c) level of ≥6.5%, this was deemed to be consistent with diabetes and coded accordingly. In the event that an HbA1c was unavailable (or the HbA1c was <6.5% at the time of their visit), a self-report of a diagnosis of diabetes, treatment with insulin or other antihyperglycemic medications and/or elevated fasting blood glucose measurements were used to identify individuals with diabetes. We excluded people who did not have a pre-existing diagnosis of diabetes and were using metformin for an off-label indication. Overall prevalence of diabetes was determined by the addition of the six diagnostic subgroups incorporated in table 1. Within the cohort of clinic patients not identified as having diabetes, further review of HbA1c and fasting blood glucose results allowed for the identification of individuals with pre-diabetes. Individuals with an HbA1c of 6.0%–6.4% (Australian Diabetes Society criteria)21 and/or a fasting blood glucose level between 5.6 mmol/L and 6.9 mmol/L (ADA criteria)22 were classified as having pre-diabetes.
Categories used to determine diabetes status in the ccCHiP cohort
Demographic data (age, gender, ethnicity and marital status) and clinical data (International Classification of Diseases, 10th Revision (ICD-10) psychiatric diagnosis, medication use, personal history of diabetes, family history of diabetes, smoking status, alcohol consumption, physical activity level, body mass index (BMI), waist:height ratio (WtoHt), blood pressure, fasting blood glucose, HbA1c, total cholesterol, triglyceride, high-density lipoprotein (HDL) cholesterol, low-density (LDL) lipoprotein cholesterol and estimated glomerular filtration rate (eGFR) are routinely collected for patients who attend the ccCHiP clinic.
Ethnicity was classified as low-risk category for diabetes when the father's or mother's country of birth was from a Mediterranean or Caucasian origin; high-risk category when African–American, Pacific Islander, Middle Eastern, Asian/Southeast Asian, Aboriginal/Torres Strait Islander, Indian subcontinent or other high-risk origin. BMI was defined as 'normal' if (18.0–<25.0 kg/m2 and low-risk ethnicity or 16.0–<23.0 kg/m2 and high-risk ethnicity), overweight (25.0–<30.0 kg/m2 and low-risk ethnicity or 23.0–<27.5 kg/m2 and high-risk ethnicity) and obese (≥30 kg/m2 and low-risk ethnicity or ≥27.5 and high-risk ethnicity).
WtoHt was categorized as elevated if an individual's WtoHt was >0.52 and low-risk ethnicity, or >0.50 and high-risk ethnicity. Abdominal circumference was categorized as normal if an individual's waist was <94.0 cm for men and low-risk ethnicity, or <90.0 cm for men and high-risk ethnicity, or <80.0 cm for women; and 'abnormal' if ≥94.0 cm for men and low-risk ethnicity, or ≥90.0 cm for men and high-risk ethnicity or ≥80.0 cm for women. Dyslipidemia was defined by the presence of one or more of the following findings: (1) prescription of cholesterol-lowering medication, (2) total cholesterol of ≥4.2 mmol/L, (3) HDL cholesterol of <1.04 mmol/L (for men) and <1.29 mmol/L for women, (4) LDL cholesterol of ≥2.59 mmol/L and (5) triglycerides of ≥1.7 mmol/L. Consumption of alcohol was categorized as 'high risk' (≥7 standard drinks/week for men and ≥5 standard drinks/week for women) and 'low risk' (<7 standard drinks/week for men and <5 standard drinks/week for women). Treatment with antipsychotic medication was categorized as (1) clozapine (±another antipsychotic medication), (2) olanzapine (±another antipsychotic medication), (3) non-clozapine/non-olanzapine antipsychotic medication and (4) no antipsychotic medication.
Data were analyzed using SAS V.9.1.4 statistical software program.23 Descriptive statistics are presented as count and percentage for discrete variables and as mean and SD for continuous variables. Prevalence of diabetes and the prevalence of pre-diabetes are both reported with their corresponding 95% CIs. The Pearson's χ2 test was used to assess for differences in the distribution of categorical variables. Logistic regression analyses were carried out to explore the association between risk factors and diabetes status. In this approach, potential risk factors against diabetes status were analyzed in a backward selection procedure. Variables with p values of < 0.10 in the univariate association were entered into the multivariate model with a p value of <0.05 being the criterion for removal of variables. ORs (with 95% CIs) for each risk factor are reported. Statistical tests were two-tailed with the significance level set at 0.05.
Characteristics of ccCHiP clinic participants
Between May 2014 and December 2019, 1402 patients with SMI were seen for a baseline visit at a ccCHiP clinic. The mean age of the ccCHiP cohort was 43.9±12.8 years; 63.1% were male; 79.0% were overweight or obese; and 50.0% were current tobacco smokers (table 2). White/Caucasian (64.0%) and Asian/Southeast Asian (17.0%) were the most frequently cited ethnicities within the clinic population. The most common psychiatric diagnosis among ccCHiP clinic attendees was schizophrenia (63.5% of the clinic cohort). For those individuals not reporting a diagnosis of schizophrenia, the primary psychiatric diagnosis was attributed to schizoaffective disorder (in 9.6% of cases), bipolar disorder (12.2% of cases), depression (4.0% of cases) and other psychosis (7.4%). Of the clinic cohort, 3.3% had another ICD-10 diagnosis recorded as their primary psychiatric illness. Table 2 demonstrates that there is a difference across various psychiatric diagnosis with the diabetes and no diabetes groups (p<0.001).
Baseline characteristics of ccCHiP clinic population by diabetes status
Diabetes and pre-diabetes prevalence
Overall, the prevalence of diabetes within the ccCHiP clinic population was found to be 23.0% (95% CI 20.8% to 25.2%) (table 2). The prevalence of diabetes was similar for men (24.0%, 95% CI 21.2% to 26.8%) and women (21.2%, 95% CI 17.7% to 24.8%). A further 19.5% (95% CI 17.4% to 21.5%) of our cohort were classified as having evidence of pre-diabetes (on the basis of an HbA1c in the 6.0%–6.4% range and/or a fasting blood glucose in the 5.6–6.9 mmol/L range). Pre-diabetes was identified in a slightly higher proportion in men than in women (21.0%, 95% CI 18.4% to 23.7% (male) vs 16.8%, 95% CI 13.6% to 20.0% (female)). Within the female cohort, 8.2% (95% CI 5.5% to 10.9%) of individuals reported a history of gestational diabetes. Of those with a history of gestational diabetes, one-third had developed diabetes mellitus by the time of their first visit to the ccCHiP clinic.
Figure 1 highlights the prevalence of diabetes mellitus (stratified by age group and sex) for the ccCHiP clinic population. These data are presented in comparison to the background, general Australian population.4 5 As can be seen, the prevalence of diabetes within the ccCHiP clinic population is substantially higher than the Australian General population across each of the 18–44, 45–54 and 55–64 years of age categories.
Prevalence of diabetes (stratified by age group and sex) for the ccCHiP population and the background, Australian general population. ccCHiP, Collaborative Centre for Cardiometabolic Health in Psychosis.
Diabetes treatment and level of glycaemic control
Of the 322 individuals classified as having diabetes according to our diagnostic criteria, 51 (15.8%) were newly diagnosed with diabetes at the time of their first ccCHiP clinic visit. Of the 271 individuals with pre-existing diabetes at the time of first ccCHiP clinic visit, 229 (84.5%) were receiving treatment with diabetic pharmacotherapy. Within the cohort of patients holding valid prescriptions for diabetic pharmacotherapy, the three most prescribed agents were metformin (216/229, 94.3%), gliclazide (or other sulfonylurea) (44/229, 19.2%) and insulin (36/229, 15.7%) (table 3). The most prescribed treatment regimen was metformin monotherapy (n=145, 63.3%). Of those with a pre-existing diagnosis of diabetes and on metformin monotherapy, 36.4% were not at the recommended HbA1c target (<7.0%) at the time of their ccCHiP visit. Approximately 37.0% were prescribed dual antihyperglycemic therapy. Sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists were the least frequently used pharmaceutical agents. Table 3 illustrates the distribution of diabetic pharmacotherapy use at the time of the initial ccCHiP clinic visit.
Diabetic pharmacotherapy use among those individuals holding at least one valid prescription for an antihyperglycemic agent at the time of initial ccCHiP clinic visit (n=229)
Ninety per cent of individuals (n=289 of the diabetes cohort) with a diagnosis of diabetes had a recent HbA1c measurement available at the time of their first clinic visit. The median HbA1c for those with a diagnosis of diabetes was 6.8% (range 4.3%–16.2%). Forty-five per cent (n=131) had an HbA1c of ≥7.0%, and 28.0% (n=82) had an HbA1c of ≥8.0%.
Diabetes and antipsychotic therapy
Thirty-five per cent of people with diabetes were receiving treatment with clozapine±other antipsychotic medication, 11.0% olanzapine±other antipsychotic medication, 47.2% were receiving treatment with non-clozapine/non-olanzapine antipsychotic medication, and 6.5% were not prescribed any antipsychotic medication.
Factors associated with diabetes in the ccCHiP population
Univariate logistic analysis revealed that age, WtoHt, father's ethnicity, mother's ethnicity, family history of diabetes, psychiatric diagnosis, consumption of alcohol, physical activity and antipsychotic treatment with clozapine±other antipsychotic medication or olanzapine±other antipsychotic medication were statistically significantly associated with diabetes (table 4). We did not find a significant association between gender and diabetes or smoking status and diabetes.
Logistic regression models of factors associated with diabetes in people with severe mental illness attending a multidisciplinary service
Multivariate logistic analysis found that older age was significantly associated with diabetes. Those with an elevated WtoHt had significantly higher odds of diabetes (OR 4.5, 95% CI 2.2 to 9.2) relative to those with a normal WtoHt. People with a family history of diabetes had twofold higher odds of diabetes (OR 2.0, 95% CI 1.5 to 2.8). Those with Aboriginal/Torres Strait Islander and Indian subcontinent maternal ethnic backgrounds had greater than threefold increased odds of diabetes relative to the Caucasian/Mediterranean ethnic group. Finally, the odds of diabetes in those treated with clozapine±other antipsychotic medication (OR 1.7, 95% CI 1.2 to 2.4) were almost twofold higher than in those treated with non-clozapine/non-olanzapine antipsychotic therapy. Treatment with olanzapine±other antipsychotic medication was associated with half the odds (OR 0.5, 95% CI 0.3 to 0.8) of having diabetes than those treated with non-clozapine/non-olanzapine antipsychotic therapy.
Throughout the world, the prevalence of diabetes mellitus continues to increase with predictions that the 2045 worldwide prevalence will reach 783 million.24 Within the cohort of people with SMI, most antipsychotic pharmacotherapy contributes to weight gain and insulin resistance. International studies have found that the prevalence of diabetes is two to three times higher in those with SMI than that observed in the general population.16 In the Australian setting, we have confirmed a significantly higher prevalence of diabetes in the SMI population than that seen in the general Australian population. In the category aged 18–44 years, diabetes prevalence in the ccCHiP population is 16.7% (>10 times higher than the age-matched, general Australian population). In the 45–54 years of age category, diabetes prevalence in the ccCHiP population is 25.9% (>6 times higher than the age-matched, general Australian population) and in the 55–64 years of age category, diabetes prevalence in the ccCHiP population is 31.7% (>3 times higher than the age-matched, general Australian population).
Within the ccCHiP cohort alone, we found that diabetes was significantly associated with older age; elevated WtoHt; presence of a family history of diabetes; maternal ethnic background being Aboriginal/Torres Strait Islander, Indian or Middle Eastern compared with Caucasian/Mediterranean, and being on clozapine or olanzapine±other antipsychotic medication compared with not using any antipsychotic medication. Comparable risk factors are prevalent in high-risk psychosis groups globally, reinforcing the notion that the diabesity 'pandemic' is even more accentuated in those with SMI.
In this study, treatment with olanzapine±other antipsychotic medication was associated with lower odds of having diabetes than those on other antipsychotic medication only. This unexpected finding was in contrast to the increased odds of diabetes observed in those on treatment with clozapine±other antipsychotic medication. One possible explanation for the discordance between olanzapine and clozapine may be driven by prescriber behavior. We observe that many prescribers in our local area are acutely aware of the orexigenic and diabetogenic effects of olanzapine and are therefore more proactive in the metabolic management of patients commenced on treatment with olanzapine. This certainly needs to be explored in future research in similar cohorts.
A significant concern for the ccCHiP service is a relatively high prevalence of undiagnosed diabetes at the time of first clinic visit. From the literature, it is estimated that up to 70% of cases with diabetes in people with SMI are undiagnosed.25 In our clinic population, over 15% of those with diabetes mellitus were newly diagnosed at the time of their first visit. Over 40% of those newly diagnosed with diabetes at the time of their first visit were aged less than 45 years.
These data support a more proactive screening approach in the young adult SMI population. It is now well recognized that early detection and assertive treatment of diabetes can be very useful in achieving better long-term outcomes.26 The high rate of undiagnosed diabetes provides a strong argument for more intensive screening for diabetes within the SMI population. It appears that screening for diabetes should start at least two decades earlier for those with SMI. Such screening also provides an opportunity to identify those who have impaired glucose tolerance or pre-diabetes. From a pragmatic point of view, screening with fasting glucose and an HbA1c level would appear to be a reasonable strategy to adopt.
Another concern for clinicians at the ccCHiP clinic is that of treatment inertia in the management of diabetes for the target cohort. For those with a pre-existing diagnosis of diabetes, >40% were not at the recommended HbA1c target (<7%) at the time of their ccCHiP visit. On review of pharmacotherapy use, it is apparent that metformin, gliclazide and insulin were the most commonly prescribed antihyperglycemic agents during the study period. In view of high levels of suboptimal glycemic control at the time of a patient's initial ccCHiP clinic appointment, diabetes treatment intensification appears currently inadequate within the local community who have SMI. In this context, a ccCHiP-like service is well placed to provide diabetes management support to primary care and local community mental healthcare teams. The relative underuse of newer, antihyperglycemic pharmacotherapies (namely, SGLT2 inhibitors and GLP-1 receptor agonists) is most likely explained by the national pharmaceutical benefit scheme prescribing restrictions that were in place for these agents during the study period (2014–2019). Moving forward, there is certainly a role for services like ccCHiP to support an increased uptake of these metabolically favorable treatments in partnership with local general practitioners.
Our study is notable for a number of strengths. The ccCHiP clinic has provided clinical services to >1400 individuals with SMI over the past 5 years, and thus this study captured data from a substantial number of individuals with SMI who reside in the Sydney Local Health District.
This study provides the first systematically collected data on cases of schizophrenia in our catchment area. The question of representativeness arises. Given the currently accepted point prevalence rate for the schizophrenias (0.28%), the catchment population size serviced (700 000) and the known number and diagnoses of persons in public psychiatric care (2200; ~65% schizophrenia spectrum), and given public clinics are the predominant setting for the treatment of SMI, we estimate that about three-quarters of suitable patients are referred to ccCHiP. There is no significant difference (age and gender) between our cohort of people with SMI and the Australian SMI population not referred to the ccCHiP Clinical Service.27 Further, referral criteria are not based on anthropometric or pathology criteria, but rather a mandate that all new patients with psychosis are assessed within a year and then between 12 and 24 months in periodic follow-up. This suggests that the ccCHiP cohort is representative of those that are managed in public psychiatric settings.
The use of a hierarchical approach to diabetes identification incorporating both HbA1c and fasting glucose data, in addition to self-report and review of pharmacotherapy, is another strength. Previous Australian studies have primarily relied on fasting glucose measurements to estimate diabetes/pre-diabetes prevalence, and in some studies, simply a self-report. Evidently, these previous studies may have resulted in a less accurate estimation than the more comprehensive approach employed in this study. It is also important to note that the ccCHiP service prospectively collects clinical data at each patient visit to the clinic, and thus missing data are kept to a minimum. In addition, the comprehensive data collected by the ccCHiP service has allowed insights into pharmacotherapy use within the cohort of patients with co-morbid SMI and diabetes. In turn this provided an opportunity to quantify the degree of diabetes treatment inertia currently faced by this high-risk population.
It is also important to recognize the study's limitations. Data presented are collected from a secondary referral service and thus may be subject to a referral bias. Nevertheless, our criteria used for referring individuals to ccCHiP clinics accommodated all people with a diagnosis of 'psychosis' which is reasonably representative of those in the Central Sydney public mental health population, as described previously. Referrals are accepted from all local healthcare providers; however, the majority of referrals are received from local community mental health services and a minority are received from within-area general practitioners. Individuals with SMI managed in the private health sector are relatively under-represented. We also acknowledge that the criteria used to identify individuals with diabetes within the ccCHiP clinic population, while more comprehensive than those used in previous Australian studies, are imperfect. Ideally, to confirm a new diagnosis of diabetes, one would normally request a second confirmatory fasting blood test. This is usually performed by the patient's GP, and the ccCHiP clinic does not have direct access to the results of confirmatory testing that may have been performed by general practitioners.
Overall, the prevalence of diabetes within the SMI population in metropolitan Sydney is significantly higher than that of the age-matched, general Australian population. Two areas of significant concern are the relatively high rates of undiagnosed diabetes in the clinic population (especially considering the elevated rates of early onset) and an apparent treatment inertia in those with an established diagnosis of diabetes. Implementation of targeted interventions via an integrated care approach may help these high-risk individuals improve their diabetes management and their cardiometabolic health.
Collection and analysis of Collaborative Centre for Cardiometabolic Health in Psychosis data were approved under REGIS 2021/ETH00456 (previously HREC/16/CRGH/101) through the Sydney Local Health Area District ethics committee. A waiver for informed consent was obtained as the study was performed on deidentified, routinely collected clinical data and carried minimal risk to participants.
The study was performed using data collected from patients attending the
Collaborative Centre for Cardiometabolic Health in Psychosis
(ccCHiP) clinics using a bespoke clinical informatics system. The authors thank the staff at the ccCHiP clinics for their assistance with data collection.
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Mitchell AJ
. Diabetes mellitus and severe mental illness: mechanisms and clinical implications. Nat Rev Endocrinol 2015;11:79–89.doi:10.1038/nrendo.2014.203pmid:http://www.ncbi.nlm.nih.gov/pubmed/25445848
Holman RR,
Paul SK,
Bethel MA, et al
. 10-Year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577–89.doi:10.1056/NEJMoa0806470pmid:http://www.ncbi.nlm.nih.gov/pubmed/18784090
Simpson A
. Understanding the profile of Sydney Local Health District's community mental health consumers. (Unpublished report) Living Well. Sydney Local Health District, Australia: Living Longer Steering Committee, 2019.
Contributors TL, RC and TM have made substantial contributions to the conception and design of the article or study, or acquisition of data. PS performed the statistical analysis and coordinated the interpretation of data with TM. TM, PS and TL were involved in the drafting of the article or revising it critically for important intellectual content. TL accepted full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish as the guarantor. All authors provided comments on drafts of the manuscript.
Funding The activities of the ccCHiP clinics are supported by the Sydney Local Health District.


text:
Adenopleurellidae är en familj av kräftdjur. Adenopleurellidae ingår i ordningen Harpacticoida, klassen Maxillopoda, fylumet leddjur och riket djur.

Familjen innehåller bara släktet Sarsocletodes.

Källor

Externa länkar

Hoppkräftor
Adenopleurellidae

redpajama_set_name: RedPajamaWikipedia


If you ever were curious about new games and holidays, then it is good to learn about Dreidel Game. Having kids makes us learn and play more, teaching them all new things and concepts. This month I received 100 Medium Plastic Dreidels. They are conveniently packed in a zip lock stand up bag, easy to take and play with you. I think they are perfect for teaching kids Dreidel Game. The size is excellent for our JK kids to play, not very small and not too big, little hands know what to do right away. And colors definitely catch your eyes: live and vivid.
4. The one with the most pennies is the winner.
The dreidels are great for schools and class games, kids are so much into it, plus quality you can definitely rely on. Safe for kids older than 3 years old. It is amazing how much children love bright colors and spinning, and the dreidels spin really well to kids' excitement. Children can choose the colors they like and take dreidels home if they want. The price of the pack is good too, 100 dreidels are around $20.


More headsets. More wireless freedom.
The Plantronics CS500 XD Wireless Headset Series was designed to address wireless density issues*, so that more wireless headsets can be used in the same space while maintaining clear conversations. Using 900 MHz technology, the CS500 XD Series provides up to 350 feet of range, and includes a convertible headset with a hot swappable battery (CS545-XD) for unlimited talk time.
With one-touch call answer/end, vol+/-, and mute, manage calls from up to 350 feet from the charging base. The CS500 XD system also enables you to conference in up to three additional headsets for easier collaboration and guest headsets can subscribe to a base by simply docking the headset. Use with Electronic Hook Switch Cable or Handset Lifter to remotely answer/end calls.
Your choice of narrow or wideband professional grade audio quality -- choose narrowband to extend talk time or wideband mode to enable clearer conversations. An extended boom and noise-canceling microphone filter out background noise, so listeners can hear conversations clearly and enhanced Digital Signal Processing (DSP) provides more natural sound, delivering clear audio the way it's intended to be heard.
A sleek charging base is included with the CS500 XD Series. An adaptive power system optimizes for range and talk time by automatically downshifting to low power when the headset is close to the base to save battery life.


Please note this product is a REFILL only, if you need to order a full system with board please see our kits.
We offer full colour printing with no cost penalty so you can promote your school identity at all times. If you have a particular pantone colour that you would like us to use then please let us know when you order.


Understanding and analysing seismic faults and their activities can be critical for locating buildings, tanks, and pipelines and assessing the seismic shaking and tsunami hazard to infrastructure and people in the vicinity.
Near-Fault Observatories (NFOs) are advanced multidisciplinary research infrastructures based on integrated networks of multi-parametric sensors continuously monitoring the chemical and physical processes governing active faults and the genesis of earthquakes. These networks complement regional seismic and geodetic networks (typically with station spacing of 50-100 km) with high-density distributions of seismic, geodetic, geochemical and geophysical sensors located in the near-distance (typically within 10-20 km) of active faults where large earthquakes are expected in the future. It is projected that over the next decade, tens of such multi-disciplinary observatories will be installed in Europe, enabling substantial advances in our fundamental understanding of earthquakes generation processes and associated ground shaking. EPOS will implement a comprehensive set of services to support the installation of these observatories.
Strengthen the connections with other related EU and global initiatives devoted to the multidisciplinary monitoring and studies of active fault zones (GEO supersites, www.marsite.eu).
Services relying on existing organizations (ORFEUS) and projects (MARsite2, EU NFOs3); Standard (seismic and geodetic) and specific (electro-magneto telluric, geochemical, geological, gravity, strain-tilt-meter and other multidisciplinary) near fault data and metadata, including borehole data (Level 0).
Virtual Laboratory (online engagement and knowledge-sharing initiative) containing multidisciplinary products (Level 1, 2, 3) and services for describing the anatomy of active faults and the causative physical processes.


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All day long on Friday, the entire spectrum of German media paid tributes to Hans-Dietrich Genscher. They were joined in the evening by the Chancellor, who 'bowed in deep respect for the lifetime's work' of the former foreign minister.
30 September 1989, Prague, German Embassy.
All of them referred to the key scene of 30 September 1989, when Genscher appeared on the balcony of the German Embassy in Prague and announced to 4000 East German citizens that had sought refuge in a hopelessly overcrowded house and garden – very literally 'huddled masses yearning to breathe free' – that he had managed to realise their transfer into the Federal Republic. The most famous unfinished sentence of German history, which so many years later is still a deeply moving memory.
How many of these 4000 desperate individuals take part today in Pegida demonstrations against migrants and asylum seekers from elsewhere, waiting jam-packed like they were themselves for an open door to a better life? Just wondering.
After Egon Bahr and Helmut Schmidt, Hans-Dietrich Genscher is yet another of those major Cold War politicians who disappears; another of those tireless networkers and negotiators whose actions have had a long-term impact on what happened on both sides of the Iron Curtain and shaped the Europe we are now living in.
No need here to reformulate the respectful tributes and obituaries that can be found in quite a few different languages on the web today. Let me just take the liberty to talk a short stroll down memory lane. To me, Genscher's death recalls just how much of democracy's stability depends on the human resources that are available at a given moment for political leadership.
In 1972, when 'international relations' entered with a loud crash the political consciousness of a ten-year old enthusiastic about the Munich Olympics, Genscher was already there, offering himself, in vain, as substitute hostage to the Palestinian terrorists. Ten years later, when I was doing my military service bravely protecting the Iron Curtain, Genscher was negotiating and implementing the NATO double-track decision. And another ten years later, my generation was actually surprised to see him retire after having led, together with Kohl and Schäuble, Germany to reunification in peace with its neighbours. A German government without Genscher? Unthinkable.
Hans-Dietrich Genscher, East Germany, February 1990.
There is of course a whole range of factors that may explain why the Bundesrepublik, which Genscher served for over two decades, turned from a fragile young republic to a anchor of democracy and freedom respected across the world, and contemporary history and political science will be happy to provide convincing explanations.
I can't help but wonder, though, whether one of these factors was not 'sheer luck'. Perhaps, after all, the Germans have simply been very, very lucky with their human resources management at the top of the state. Lucky that those individuals who made it to key positions were really up to the job. And even luckier that those who might well not have been up to it and jeopardised the development of the Republic – think of Strauss, Stoiber, Lafontaine and the like – failed on the doorstep of power.
Luck is not a concept of any serious political theory I know of, but the simple observation of the current development of democracy suggests that countries which can count on human resources like Hans-Dietrich Genscher may well be entitled to call themselves lucky.
This entry was posted in Current Affairs, Democracy & Citizenship and tagged democracy, Germany. Bookmark the permalink.
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redpajama_set_name: RedPajamaGithub


text:
Venture Construction Group of Florida Sponsors Team Evolve in Emerald Coast Mudrun
Home/Annual Giving, Philanthropy, Philanthropy, Press Releases, Venture Construction Group of Florida/Venture Construction Group of Florida Sponsors Team Evolve in Emerald Coast Mudrun
Florida Commercial Restoration Company Supports Mudrun for Orphans
NICEVILLE, Fla. — Venture Construction Group of Florida (VCGFL), the Premier Platinum sponsor of Team EVOLVE, joined thousands of runners for the 8th Annual Emerald Coast Mudrun for Orphans on May 18 in Niceville. The event included challenging obstacle course races, family fun festival, and live music. The fundraiser supports orphans around the world through nonprofit organization Heart of the Bride for Orphans.
"The Mudrun was a great opportunity to have some fun with obstacles all while supporting a good cause. It feels great knowing all proceeds went to orphans in need around the world," says Jason Cameron, disaster restoration specialist, Venture Construction Group of Florida.
The day launched with a 10K Elite Warrior race at 8:00am, a 5K Competitor race at 9:00am, a 5K Fun Run at 9:30am and 11:30am, a 1-mile Kids Run at 1:30pm and 2:30pm, and a 5K Zero Dark Dirty race at 8:00pm. All participants received a T-Shirt and a finisher medal. The Zero Dark Dirty race also included a head lamp and glow sticks.
Based in Niceville, Heart of the Bride currently supports nearly 500 orphans and at-risk children in five different countries around the world including Zambia, Kenya, Haiti, India, and Crimea. The support from the community and annual fundraisers has helped raise over $533,000 for orphan care.
Team EVOLVE is a group of community members participating in a variety of Obstacle Course Races and other challenges throughout the year. The team is comprised of VCGFL staff member Jason Cameron, local businesses, and Bay County Sheriff's Office employees and their family members and led by coach JT Thompson.
Upcoming races for Team Evolve include the Barbarian Challenge on June 15 in Gardsden, Ala.; the Savage Rage on Sept. 21 in Dallas, Ga.; The Bonefrog Challenge on October 19th in Charlotte North Carolina and the Tough Mudder Classic on Nov. 9 in Atlanta, Ga.
"We are truly grateful for the sponsorship from Venture Construction Group of Florida. Thanks to their support and the support from other local businesses, we can continue to grow and participate in a big way," says JT Thompson, CEO and founder, Evolve with JT.
As a leading commercial construction and storm damage restoration company dedicated to helping property owners before, during, and after the storm, VCGFL is a major advocate for giving back and supporting employee development.
About Team EVOLVE
Team Evolve is an obstacle course race team and training program under the direction of Coach JT Thompson. At Team Evolve, we provide a one-of-a kind-team environment that focuses on both individuality and teamwork, which fundamentally transforms each person, both on and off the field. The team has been featured in several media stories and has participated in several fundraising events to give back to the community. Learn more at https://www.evolvewithjt.com/teamevolve.
About Heart of the Bride for Orphans
Heart of the Bride was established in 1998 as a non-profit organization dedicated to helping provide for the needs of orphans around the world. Our mission is to share from our abundance with those greatest in need. We provide services to orphans and widows around the world by constructing orphanages and other facilities, delivering food and other resources, providing life training, and fostering relationships to improve the likelihood for self-sufficient lives through Christian leadership, discipleship, and ministry. Heart of the Bride is a member of the Evangelical Council for Financial Accountability (ECFA) – proof that HOB meets the highest standards of financial and ethical accountability. Learn more at www.HeartOfTheBride.org.
Em: info@elev8cg.com
By Venture Construction Group of Florida| 2020-04-15T21:52:53+00:00	June 19th, 2019|Annual Giving, Philanthropy, Philanthropy, Press Releases, Venture Construction Group of Florida|Comments Off on Venture Construction Group of Florida Sponsors Team Evolve in Emerald Coast Mudrun

redpajama_set_name: RedPajamaCommonCrawl


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Description: The antique Holophane style shade does an excellent job refracting light through its manganese dioxide rich glass giving the glass a lovely purplish tint. Along the 2 1/4 inch fitter neck reads "Jefferson" and "3013 PATD SEP 20 1910"
Measurements: The fixture has 101 inches of SVT/2 rayon covered wire cord. The fixture can be adjusted to a smaller length by adjusting and removing the excess cord. The shade is 8 3/4 inches across.
Condition: The light features a new cloth cord pendant fixture with nickel ceiling canopy, socket, and shade holder. The fixture includes a 60-watt mirror light bulb and mounting hardware. The antique glass shade is in good condition.
Electrical: The fixture uses a standard medium base bulb. Suitable for dry locations. Use 60-watt bulb.


Mahamudul Hassan Tonmoy (Independent University, Bangladesh) and Ridwanul Arefin Arnob (Bangladesh University of Professionals) at the International Young Innovators Summit-2018 held in Tokyo recently.
Bangladesh achieved the 'Best Idea Innovation Award' with the project namely 'Cure' among the top 50 projects from the world in the International Young Innovators Summit-2018. The summit was officially organized by Studec International and Japan Student Services Organization (JASSO) held in Tokyo from October 8-11. The main theme of this summit was "Designing Innovation for the Better World".
International Young Innovators Summit is the youth conference that connecting aspiring young innovators with international speakers from the innovators experts, lecturers, innovators influencer from different backgrounds. Entering the first annual session, this summit aims to bring together 50 young innovators into global networks and experience in international conference. Our goals are to enrich the essential skills and knowledge for the future innovators, encourage to identity and think the world's problems with creative solution and preparing the participants as the innovators for the better world.
After two rounds of elections from all over the world, Top 50 projects were invited to present their work in Tokyo, Japan.
A project called 'Cure' was also selected from Bangladesh. As a representative of Bangladesh, Mahamudul Hassan Tonmoy (Independent University, Bangladesh) and Ridwanul Arefin Arnob (Bangladesh University of Professionals) were present along with their project 'Cure'. They won the 'Best Idea Innovation Award' for Bangladesh.


SMH: Teen Goes Off On Cops While Handcuffed & Getting Questioned!
"A record-holding Indian stuntman known for using his long hair in weird ways died Sunday as he attempted to cross a river on a zip-line attached to his ponytail. Officials say Sailendra Nath Roy, 49, was halfway across the Teesta River in West Bengal when he suffered a massive heart attack and died. His body, held to the wire by his ponytail 70 feet above the river, hung for nearly 45 minutes as horrified spectators, who had come to cheer him on, watched from a nearby bridge."


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text:
RPG Insanity
Home of the Ultimate Kemco Fansite
Alvastia Chronicles
User reviews rating score:
Battle System:
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There is 1 review for 'Alvastia Chronicles'.
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Emrys Ozmyn says:
Brief Review + Side Quest #17 to #20 Solution! (at bottom)
First of all, I would like to thank Kemco for these amazing RPG's. To me, being an 80's kid growing up with the classic games in the 90's, these games are top notch by almost all accounts. I would also like to point out that even though I only started playing Kemco games in 2017, the company is now on my top 5 list of RPG developers.
Okay, now, to get on with it. I am sorry if this review is both short and lacking detail, but I will give the honorable mentions, the good and bad, as well as what I personally got out of the game.
So far out of the 10 Kemco games I have mastered, I really enjoyed Dragon Sinker most as it is my favorite thus far.
Alvastia Chronicles is a wonderful world in which you can freely explore without having to physically travel to do your back tracking via map screen. This makes it easier to get what you need done. There are multiple locations in which you can traverse (like the other titles). Alvastia Chronicles gives you the option to recruit up to 100 companions for your custom team and take on anything with your own setup. In this game, you obtain 2 other forms of transportation as you are eventually able to explore without restrictions. The game is beautiful and the characters although are not the most memorable, but had their moments (Gil for example). While playing Alvastia Chronicles, you will be able to occasionally find Old Chests after battle and set them in a menu (much like the garden feature in other Kemco games). The Old Chests have four rarity types which are straight forward (one to four stars) and can take up to 2 hours to get results. If you do not wish to wait for the chests to open, you can buy Old Keys in the shop menu, or obtain them within the game's progression. Much like Dragon Sinker and a few other titles, Alvastia Chronicles gives you the three main battle teams and the game lets you select three allies to recruit to each.
The battle system is much the same as most other titles, but you have a "Burst" option where you can have one member from each team to initiate an action. Setting up your team just right will help you pull off powerful combos.
While the battles in this game specifically are very easy on all modes compared to most other Kemco titles, it is still very fun to level grind and collect content as well as party buffing items that are very common.
While I was only familiar with the Maid aspect of most other Kemco titles, the Butler aspect for this game was much the same, and you can test your medal in the tournament, plus the hidden tournament.
You can get 100% game completion in under 20 hours, so the game doesn't have much to it at all. Despite being very short, the game is overall a good one. I personally enjoyed it, but it was a bit too easy. I don't know if there is an Alvastia Chronicles II out there, or a spin-off, but I for one would sure play it.
This is my very first public review of any game, so it may not be as thorough to some readers who require more content. Anyway, I hope this was at least decent for those who have not yet played Alvastia Chronicles, or would like to know a bit more about it. Thank you, everyone and I look forward to any, if at all input you might have.
Side Quests #17 to #20 Solution
I would like to post information about a common issue that this game had according to myself and many others. It is about Side Quest #20. It would seem that the quest client was either glitched or just non-existent upon many attempts that left a lot of players frustrated. I have found my own solution for the issue however and shared it with many others online. If you are familiar with this Side Quest #20 issue, then pull your hair out no more! 🙂
Normally when you complete a Side Quest (SQ) in this game, the Relay Stones will automatically resolve the quest for you and let you claim your reward through the Side Quest menu, but in the case of the SQ #17 to #20 dilemma, you have to physically travel to those three clients to activate the next quest. (this is my best guess as that's how it worked for me).
Okay, so, after SQ #19, you have to physically travel back to the client in order to conclude that the quest is resolved (It was the only SQ in the game that required me to do, personally). If I remember correctly, the SQ #19 client is located in the third town from the top of your map. Once you talk to her, SQ #20 will activate! Go back to the location of that #20 client and go from there! I was finally able to get the Platinum Trophy just last night. And I figured out this solution by accident after getting frustrated and had to revisit all locations just in case. I actually thought about deleting the game, re-downloading it, and starting the game over… But then I thought that the client for SQ #20 might be in a different location (hence running into client of SQ #19 by accident…) I also heard that a few others had the same problem, but with SQ's #17 to #19 as well. I am assuming here that the solution is the same as SQ #20. Go back to the quest clients and speak to them directly, then, you are finished! 🙂
Easy and Relaxing Level Grinding fun where you can enjoy traveling without much worries.
HP and Status is fully Restored After Each Battle.
The Companion Feature is Fun, and meeting their requirements for recruitment keeps you compelled.
Wide Exploration that is easy because of the warp option on the map screen.
While the Storyline is fair, the characters lacked... well, character.
Treasure chests found are mostly items that you don't use often enough, so treasure hunting wasn't anticipated much.
The Butler feature was very dull and didn't have much to it's mechanics.
Rate this item: Thumb UpThumb Down
Rating: +6. From 6 votes.
Tips to make +999 weapon fast
Quest List?
Treasury List
Quest 32
Secret Battle Arena Location?
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April 2005, Enabling users to identify trustworthy actors is a key design concern in online systems and expertise is a core dimension of trustworthiness. In this paper, we investigate (1) users' ability to identify expertise in advice and (2) effects of media bias in different representations. In a laboratory study, we presented 160 participants with two advisors -- one represented by text-only; the other represented by one of four alternate formats: video, audio, avatar, or photo+text. Unknown to the participants, one was an expert (i.e. trained) and the other was a non-expert (i.e. untrained). We observed participants' advice seeking behavior under financial risk as an indicator of their trust in the advisor. For all rich media representations, participants were able to identify the expert, but we also found a tendency for seeking video and audio advice, irrespective of expertise. Avatar advice, in contrast, was rarely sought, but -- like the other rich media representations -- was seen as more enjoyable and friendly than text-only advice. In a future step we plan to analyze our data for effects on advice uptake.


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Visit the Retreats page for details on these retreats.
Welcome to our website. I am Denise Green, and I am a quilter! I enjoy all aspects of quilting but consider myself the CEO at HollyDee Quilts. CEO is for "Chief Encouragement Officer" I love teaching and sharing my love for quilting and making handcrafted items. Watching students progress through the quilting process brings me great joy. I made my first quilts in 1995 and have immersed myself from that time. As a certified Judy Niemeyer Instructor I have had the opportunity to work with students all across the US.
In 2016 we embarked on the biggest quilting adventure, we opened a brick and mortar shop in Luling, TX. (South Central TX, just south of Austin, east of San Antonio and west of Houston). We enjoy visiting with quilters from all over the world as they head to our town for some of the best BBQ in the state. We love our small town and hope you will too!
Our first 20 years in TX were in the Clearlake area, I joined the Lakeview Quilters Guild. Through the guild, I am honored to have collaborated on many projects with other members, including Cynthia England and Susan H. Garman. I also served on numerous committees and board positions with the guild including two terms as President of the guild and as Quilt Show Chair for 2 very successful shows.
In 1999 I bought my first longarm quilting machine and after practicing for may years I was asked to quilt several of the quilts for Cynthia Englands most recent book. Here is Cynthia England's Windswept Roses quilt, shown left, which appears in Cynthia's book Picture Piecing Traditional Quilts. The full quilt is shown below. This beautiful book is available on the Books page of our store.


120 Old Broad Street offers state-of-the-art facilities, and a wide range of specialties including dermatology, cardiology, general medicine and gastroenterology. They also offer a comprehensive women's health service with expert Consultant Gynaecologists.
31 Old Broad Street is an advanced private medical centre in the heart of the City, offering world-class facilities and the very latest in medical technology. In addition to GP service, the medical centre offers cosmetic surgery, physiotherapy, pain management and dermatology.
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text:
\section{Introduction}\label{sec0}
Fluids confined to nano-cavities, or restricted to surfaces are pervasive in nature \cite{Stanley:99}.  Such nano-confinement often gives rise to unusual physical properties, that are distinct from those in the bulk liquid \cite{Chaplin:09,Sliwinska:12}. In the case of water, nano-confinement suppresses crystallization altogether,  modifying the water phase diagram and leading to a metastable supercooled liquid.   Nano-porous carbon compounds are perfect examples of confining media that have inspired research on supercooled water \cite{Zhang:09a,Kolesnikov:04}, and that continue to stimulate applied research for developing for example high-performing membranes for water desalination, nanofluidic devices, and alternative drug delivery methods\cite{Striolo:07}.

The dynamical properties of supercooled water constrained in cylindrical pores have been extensively investigated with neutron scattering using various hydrophilic silica materials  such as MCM-14 or FSM-12 \cite{Faraone:04,Chen:06a,Liu:06,Takahara:05,Chu:10,Diallo:12}, and some hydrophobic carbon systems such as carbide-derived carbon (CDC)\cite{Chathoh:11}, single-wall (SWNT)\cite{Mamontov:06}, and double-wall nanotubes (DWNT) \cite{Mamontov:06,Chu:07}.   In real physical systems however, water confinement occurs under various spatial and geometrical restrictions. Understanding not only  the effects of varying pore size on the structural and dynamical properties of water, but also the influence of different pore shapes is thus of great scientific importance.

The present study aims to understand how supercooled water behaves when it is confined inside a hydrophobic pore structure that is non-cylindrical, and thereby evaluate the effect of geometry on the water dynamics. Specifically, we here examine  the characteristic diffusive dynamics of water confined in the narrow pores of Activated Carbon Fiber (ACF-10) using Quasi-Elastic Neutron Scattering (QENS).   The observed average characteristic relaxation $\langle \tau\rangle$  and diffusion coefficient $D$  (associated with the hydrogen sites of water) indicate a diffusion that is slower than in the bulk liquid, with an Arrhenius behavior with characteristic energy  barriers $E_A$ in the range $14\le E_A\le29$ kJ/mol, depending on the fit model of various characteristic parameters.  Our molecular dynamics  simulation of water  confined between two parallel flat graphene-surfaces, while not fully representative of the real physical system, shows qualitatively the same systematic trend with temperature, with an $E_A\simeq19$ kJ/mol. By comparing the present findings with previous experimental observations, we conclude that at any given thermodynamic condition, it is primarily the confining pore dimension, and not its geometry, that dictates the dynamical behavior of confined water. The measured and calculated intrinsic intermediate scattering function  $I_{in}(Q,t)$ (or self-correlation function) at ambient conditions could be satisfactorily reconciled at the low momentum transfer $Q$ ($\le$0.9 \AA${^{-1}}$), where localized dynamics are not as relevant.

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig1.eps}
\caption{(Color online) Temperature dependence of the integrated elastic scattering $I(T)$ of water confined in ACF-10, at a few selected momentum transfers $Q$. Data are normalized with respect to the lowest temperature $(T_0=100)$ K, as indicated. The onset of observable diffusive dynamics on BASIS is marked by the departure from a monotonically varying slope in $I(T)$ at low temperatures to a more rapidly changing slope at the higher temperatures. The  solid lines are model fits to data, corresponding to an activation energy $E_A=$14-15 kJ/mol.}
\label{fig.1}
\end{figure}

\begin{figure}
\includegraphics[width=1.\linewidth]{fig2.eps}
\caption{(Color online) Representative spectrum of water in AFC-10  at $Q=0.5$ \AA$^{-1}$, as observed on BASIS, plotted with the measured BASIS resolution function at 50 K (blue dashed line). Data at 280 K (top panel) and at 250K (bottom panel) are shown. The open circles represent the total observed signal from the water wetted ACF-10 sample in the Al holder. The red solid lines are model fits to the experimental data, as discussed in the text.}
\label{fig.2}
\end{figure}

\section{Neutron Experiments} \label{sec:exp}
In this section, we describe the ACF-10 sample, and the various steps involved in preparing for the neutron measurements. We also discuss the actual measurements performed on the backscattering spectrometer (BASIS) at Oak Ridge National Laboratory (ORNL), USA \cite{Mamontov:11}. This inverted geometry spectrometer has an excellent energy resolution of 3.5 $\mu$eV (2 $\times$ Half-Width-at-Half-Maximum = 2  $\times \Gamma_r$) at the elastic line, and covers a momentum $Q$ and energy $E$ transfer range, respectively 0.3 $\le Q\le$ 1.9 {\AA}$^{-1}$, and  -0.12 $\le E\le$ 0.12  meV when operated  with incident neutron beam with wavelength $\lambda_i=$ 6.4 {\AA} ($\Delta\lambda_i=\pm0.5$ \AA), corresponding to an energy bandwidth of 1.71 $\le E_i \le$ 2.35 meV.

\subsection{Sample Details}
The Kynol\texttrademark $^*$ ACF-10 (ACF-1603-10) sample was provided to us by American Technical Trading (ATT), NY.  With its human hair-like appearance, this activated carbon fiber  is reported  to have an \lq average' length of 2-4 mm, and diameter $\sim$ 10 $\mu$m, which is consistent with our transmission electron microscopy conducted at the Oak Ridge National Laboratory's Center of Nanophase Materials Sciences.  Previously reported scanning tunneling microscopy (STM) of ACF-10 \cite{Kaneko:92a,Daley:96,Parades:01} has revealed a highly sinuous pore network with a predominant and uniform nanometer size pore distribution ($\sim$90\% of the total pore volume of $\sim$0.4-0.5 cc/g determined from N$_2$ adsorption isotherms \cite{Daley:96,LiuW:14}). The remainder of the pore volume consists of largely random mesopores and some ultra-micropores. Various other measurements including thermodynamics\cite{Kaneko:92a, Kaneko:92b}, small-angle neutron and X-ray scattering \cite{Suzuki:92,Ramsay:98} of ACF-10 have also confirmed the interconnected pore structure of ACF-10, which is made primarily of elongated curvy slit-pores.  The pores themselves are just the voids or gaps between distorted (curled or curved, and not necessarily parallel) graphene sheets,  much like empty spaces within a dense pile of potato chips, but comparatively smaller \cite{Hayes:14}.   The key here is that the pores in ACF-10 are clearly not of the cylindrical-type as in the carbon or silica nanotubes, but rather of irregular slit-geometry, as evidenced in STM. This different pore structure offers a new platform for investigating fluids in confined geometries, in non-cylindrical shaped pores and evaluate the effect of pore geometry.  For the current ACF-10 sample, the micropore size distribution is $\sim$11.6$\pm$4 {\AA}, as determined from N$_2$ adsorption isotherms  \cite{Daley:96,LiuW:14} using the Dubnin-Astakhov equation \cite{Dubinin:89}. The nominal sample specific surface area is about 1000 m$^2$/g,  as confirmed at the time of manufacture by iodine number testing, which correlates well with BET calculations in this range \cite{Daley:96}.

To prepare for the neutron experiments, we outgassed the as-provided ACF-10 sample for 36 hours at 473 K in a vacuum oven to remove all of the bulk-like water, and most of the surface water that was originally present in the as-received sample. We  then exposed approximately 2.3 grams of the \lq dried' batch to 99.9\% humidity in a desiccator for several hours. The hydration level reached after 24 hours was 21\%, as determined from the relative weight change of the sample. This rather important hydration level signals the possible presence of  hydrophilic groups (oxygenated) in an otherwise totally hydrophobic sample. Since this hydration amount is relative to the ' drying' conditions set above, the diffusive dynamics reported in this work are those of all water molecules present inside the porous carbon network.  The neutron being primarily sensitive to hydrogen atoms in QENS measurements, the measurements yield the characteristic relaxations of all confined water molecules.  The hydrated sample was thus carefully loaded within a 2 mm gap of two concentric Al cylinders to minimize multiple scattering. The subsequently indium-sealed containers were anchored to the copper finger of a close-cycle refrigerator (CCR) stick which allowed to control the sample temperature between 20 to 500 K, within $\pm$0.02 K.

\subsection{Elastic Incoherent Scattering}
We started our neutron measurements with a rapid collection of elastic scattering data  of the hydrated ACF sample, on cooling it from room temperature down to $\sim$100 K. The purpose of these scans were two-fold; (1) to investigate the absence of bulk-like water in the samples, and (2) to determine a temperature range where the dynamics can be suitably studied on the spectrometer. Fig. \ref{fig.1} shows the integrated elastic intensity $I(T)$ as a function of temperature for selected $Q$, normalized to the lowest temperature data collected at 100 K such that $I(T)/I(T_0)$ equals unity. The elastic intensity at each temperature was obtained by integrating the corresponding spectrum around its elastic peak, over a small energy range $\pm2\Gamma_r $, corresponding to the resolution width. Assuming an isotropic harmonic system, we can expect the elastic intensity to be proportional to $\exp{[-Q^2\langle r^2(T)\rangle/3]}$ \cite{Chen:99,Magazu:08}, where $\langle r^2(T)\rangle$ represents the mean square displacement associated with the hydrogen atoms in the water molecules. An increase in $\langle r^2(T)\rangle$ as a function increasing temperature  indicates an increased in mobility of the H-sites of water, and so of water itself. As a result, the elastic intensity  within  the 3.5 $\mu$eV energy resolution  would effectively increase with decreasing temperature until it reaches a maximum (plateau region at about 150 K). Crystallization, if present, would be observed as an abrupt change in $I(T)$, which is not seen here at any $Q$. This suggests that the adsorbed water does not solidify and remains mobile down to at least 150 K.

 Assuming that the diffusion process responsible for the observed drop in $I(T)$ has a unimodal and continuous diffusion (single Lorentzian), with temperature dependent width $\Gamma(T)\propto \exp(-E_A/RT)$, the normalized $I(T)$ at each $Q$ can  be fitted using the following expression \cite{Springer:77},

\begin{equation}
I(T)= A_0+(1-A_0)\arctan\left(\frac{\Gamma_r}{\Gamma(T)}\right)
\label{eq:EIS}
\end{equation}
\noindent where $\Gamma_r$ is the half-width of the instrument resolution, defined previously, and $A_0$ a fraction estimate of the observable molecules that do not participate in the diffusion process.  Fitted $E_A$ values are displayed in Table \ref{tab.2}. The solid lines in Fig. \ref{fig.1} represent the fits obtained, and corresponds to $E_A\simeq 14-15$ KJ/mol.

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig3.eps}
\caption{(Color online) Plot of the fraction of elastic intensity ($x(Q)$ or elastic intensity structure factor ($EISF$)) (top panel) , and the relative weight of the narrowest Lorentzian $\alpha_{L_2}$ (bottom panel) as a function of momentum $Q$ and temperature $T$. Corresponding temperatures are shown in the legend. Colored solid lines are fits of the generic model for localized dynamics, discussed in the text. The $x(Q)$ parameter  is much more sensitive to $Q$ than it is to $T$, while $\alpha_{L_2}$ reveals a rather strong dependence on $Q$ and $T$.}
\label{fig.3}
\end{figure}

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig4.eps}
\caption{(Color online) Temperature dependence of the Lorentzian linewidths ($\Gamma_1$ and $\Gamma_2$) as a function of $Q^2$. The solid symbols are experimental values, and the dashed lines  fits of the jump diffusion model. }
\label{fig.4}
\end{figure}

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig5.eps}
\caption{(Color online) Inverse average relaxation time observed with a KWW model plotted as a function of $Q^2$ for 230 $\le T\le$ 280 K. The solid symbols are experimental values, and the dashed lines fits of the jump diffusion model.}
\label{fig.5}
\end{figure}

\subsection{Quasi-Elastic Scattering (QENS)}
Having determined a suitable temperature range for investigating the diffusion of water in ACF-10 on the spectrometer, we collected high statistical quality QENS data at six temperatures: 280, 270, 260, 250, 240 and 230 K for the hydrated ACF-10 sample.  The range of relevant momentum transfer for these QENS measurements  is 0.5 $\le Q\le$1.7  {\AA}$^{-1}$, $\Delta Q=0.2$ \AA$^{-1}$.  Fig. \ref{fig.2} depicts representative spectra at two temperatures for $Q=0.5$ \AA$^{-1}$, plotted against a spectrum obtained at 50 K, which is taken as the instrument resolution function. Below, we discuss our analysis  of the QENS data, from which we determine valuable parameters such as the diffusion coefficient, and characteristic relaxation time for the water's hydrogen sites, as a function of temperature.

\begin{figure}
\includegraphics[width=1.0\linewidth]{fig6.eps}
\caption{(Color online) Average diffusion coefficient  as a function of $1000/T$. Other reference data are shown for comparison. Dashed lines are fits to an Arrhenius behavior $\sim D_0 e^{-E_a/RT}$}
\label{fig.6}
\end{figure}

\begin{figure}
\includegraphics[width=1.0\linewidth]{fig7.eps}
\caption{(Color online) Average relaxation time of water confined in ACF-10 as a function of $1000/T$. Data for bulk water \cite{Teixeira:85,Takahara:05}, and for water confined in single-wall carbon nanotubes (SWNT)\cite{Mamontov:06} are shown for comparison. The molecular dynamics simulation (MD) results at 0.45 {\AA}$^{-1}$ fitted with the corresponding $KWW$ model are also shown.  Dashed lines are fits to an Arrhenius temperature dependence. For meaningful comparison with the SWNT, the ACF values are those obtained  using the same jump model in Ref. \onlinecite{Mamontov:06}.  Eq. \ref{eq.tauJump} applied to both data leads to somewhat lower values but similar temperature dependence.}
\label{fig.7}
\end{figure}

\begin{table}
\caption{Activation energy (rounded to the nearest integer) obtained from various sources. Values from fits of Eq. \ref{eq:EIS} to the $I(T)$ shown in Fig. \ref{fig.1}, and from the Arrhenius temperature dependent diffusion coefficients (Slow (2), KWW, MD, and bulk), as determined from Fig. \ref{fig.6} are shown.}
\label{tab.2}
\begin{ruledtabular}
\begin{tabular}{ c   c c c c c c}
Source      &$I(T)$  & $D_2$ & $D_{KWW}$ & MD & Bulk\\
\hline
$E_A$ (kJ/mol) & 15 & 14 & 29 & 22 & 24
\end{tabular}
\end{ruledtabular}
\end{table}

\subsection{Data Analysis } \label{sec:dan}
To analyze the experimental QENS data, we fitted it the observed spectra $S(Q,E)$ at each $Q$ and temperature point to a model function $S_m(Q,E)$ convoluted with the instrument resolution function $R(Q,E)$, plus a linear background term $B(Q,E)$;
\begin{equation}
S(Q,E)=S_m(Q,E)\otimes R(Q,E) +B(Q,E).
\end{equation}
\noindent Within the spectrometer energy window, our model $S_m(Q,E)$ function can be separated into two terms; an elastic part due to \lq static'  water molecules and a diffusive term $S_d(Q,E)$  coming from the dynamics of the molecules. If we denote the fraction of immobile water molecules by $x(Q)$ (commonly referred to as elastic incoherent structure factor or $EISF$), this model becomes,
  \begin{eqnarray}
  S_{m}(Q,E)= x(Q)\times\delta(E)+(1-x(Q))\times S_{d}(Q,E)
 \label{eq.IQ}
 \end{eqnarray}
\noindent where $S_d(E)$ represents the diffusive component of the scattering.

\section{Molecular Dynamics}\label{sec:MD}
Here we discuss the methodology employed in our molecular dynamics studies. Computer simulations coupled with QENS provide unparalled insights that are often impossible to obtain with experimental or theoretical approach alone. To further investigate the confinement and temperature effects on the water dynamics using molecular dynamics simulations, we study the time evolution of the intermediate scattering functions (ISF) for the water-hydrogen sites, $I_{in}(Q,t)=\langle \exp \left( iQ[{\bf r}_j(t_0+t)-{\bf r}_j(t_0)]\right)\rangle$, where ${\bf r}_j(t)$  is the position of the hydrogen-site $j$ at time $t$, $Q$ is the wavenumber (or momentum transfer), where $\langle \dots\rangle$  represents the averaging over all $j$-sites and time origins $t_0$ \cite{Chialvo:13,Chialvo:14}.  For that purpose we used a pair of flat grapheme plates, $L_x=28.40$ {\AA} by $L_y=30.74$ {\AA} , with an inter-plate separation $h=11.6$ \AA.  Each graphene plate comprised 364 carbon sites described atomistically as Lennard-Jones spheres characterized by   $\epsilon_{cc}/k=28$ K and $\sigma_{cc}/k=3.40$ {\AA}   \cite{Steele:73,Striolo:04}. These plates were immersed into an aqueous fluctuating cubic simulation box to perform isobaric-isothermal molecular dynamics at ambient pressure and temperatures in the range $220\le T \le 280$ K , according to a Nos\'e-Poincare symplectic integration algorithm \cite{Nose:01, Okumura:07} with a time-step of 2.0 fs, where the aqueous environment consists of 2048 SPC/E water molecules \cite{Berendsen:87}.

According to the time-dependent configurational trajectories from simulation we calculated  $I_{in}(Q,t)$ at four $Q$-values, i.e., 1.80, 1.35, 0.90, and 0.45 {\AA}$^{-1}$ corresponding roughly to the intrinsic length-scales characterizing the system, within a time span of about 500 picoseconds. Additional details regarding the simulations are given elsewhere  \cite{Chialvo:13,Chialvo:14}.  To characterize the dynamics of confined water and its temperature response we regressed the simulated   $I_{in}(Q,t)$ in terms of either a two-exponential function,  $\alpha\exp(-t/\tau_1)+(1-\alpha)\exp(-t/\tau_2)$, or a stretched exponential function,  $\exp[-(t/\tau_s)^\beta]$, characterized by the relaxation time   $\tau_s$ and the stretching exponent  $\beta$.

\section{Results and Discussion}
To accurately represent all diffusive processes of water, the scattering model $S_d(Q,E)$ in Eq. \ref{eq.IQ} would ideally be a sum of several Lorentzian functions $\sum_i\frac{\Gamma_i}{E^2+\Gamma_i^2}$, each accounting for a specific diffusion $i$ in the sample. In practice however,  QENS data are most reliably characterized by no more than 2 Lorentzians (2L), still providing reasonable representation of all relevant diffusion processes. In general for water, the 2L model  works well for an instrument with broad dynamics range such as BASIS, and consists of a fast component, with characteristic width $\Gamma_1$, and a slow component with width $\Gamma_2$ . The fast component is generally associated with diffusion inside a \lq transient' cage (with say radius $a_1$) made of other water molecules, and the slow component with inter-cage diffusion \cite{Qvist:11}. In most instances however, whether the 2L is suitable or not,  a stretched exponential model (referred to as Kohlrausch-Williams-Watts (KWW) \cite{Chen:99,Li:12} from now on (i.e. $e^{-(t/\tau)^{\beta}}$ in the time domain or its Fourier-Transform in energy space) can always be used to represent the distribution of proton dynamics present in the sample.  We have used  both models to fit the data - not only for quantifying the dynamics, but also for determining the best model for our particular system.  We kept the stretching exponent $\beta$ fixed to 0.5  at all temperatures for convenience.  Our  goal was to systematically compare the average relaxation time and diffusion coefficient based on the two models. The other important aim was to compare the experimentally determined characteristic parameters with those obtained in previous experiments with single-wall nanotubes (SWNT), and from molecular dynamics simulations to which we return below. Interestingly, we find that the KWW model yields a better agreement between the simulated and measured diffusion coefficients $D$, despite the fact that both  models are able to reliably capture the experimentally observed values. In the 2L model however, $D$ could only be determined from the slower diffusive component, as generally found in confined systems \cite{Zanotti:99a}. We could not extract $D$ for the broad component because $\Gamma_1$ does not go to zero at low $Q$, as is expected in confined diffusion. Assuming a 2L model with Lorentzian components $L_1(Q,E)$ and $L_2(Q,E)$, $S_d(Q,E)$ can be written as,

\begin{equation}
S_d(Q,E)=(1-\alpha_{L_2}(Q))L_1(Q,E)+\alpha_{L_2}(Q)L_2(Q,E)
\label{eq.2L}
\end{equation}
\noindent where $\alpha_{L_2}(Q)$ is the relative weight of the narrow Lorentzian $L_2(Q,E)$. The $Q$-dependence of this parameter and that of the $x(Q)$ in Eq. \ref{eq.IQ}, which are displayed in Fig. \ref{fig.3}, can provide important details regarding the spatial extent of the confined diffusion in the ACF-10 sample.   We find an $x(Q)$ that varies little with temperature $T$  but noticeably with momentum transfer $Q$.  In contrast, the parameter $\alpha_{L_2}(Q)$ reveals a rather strong systematic dependence on both $Q$ and $T$. This allows to estimate the corresponding confining radius $a_1$ associated with the transient dynamical restriction by fitting  $\alpha_{L_2}$ to a generic  localized $EISF$ model $\left[ f + (1-f)\left(\frac{3j_1(Q a_i)}{Q a_i}\right)^2\right]$ \cite{Zanotti:99}. The corresponding fits are indicated by the solid lines in Fig. \ref{fig.3} for both $\alpha_{L_2}(Q)$ and $x(Q)$.  In the case of  $x(Q)$, the radius $a_0$ extracted yields the spatial confinement due to the nanopores in ACF-10, which is not  expected to vary significantly with temperature, as observed here. The fitted values are summarized in Table \ref{tab.1}.  Within a satisfactory fit uncertainty of 10 to 15\% ($\sim$ 0.3-0.7 \AA), we find a clear systematic reduction of the transient confining radius $a_1$ with decreasing temperature, while $f$ increases.

\begin{table}
\caption{Temperature dependence of the confining radius (in {\AA}) determined from model fit to the elastic parameter $x(Q)$, and the weight fraction of the second Lorentzian $\alpha_{L_2}$.}
\label{tab.1}
\begin{ruledtabular}
\begin{tabular}{c | c c c c c c c}
T (K) & 280 & 270 & 260 & 250 & 240 & 230 \\
\hline
$a_0 ({\AA})$ & 5.64 & 4.97 & 4.75& 4.70 & 4.80 & 4.10\\
$a_1$ ({\AA}) &  5.44 & 3.36  & 3.08  & 3.03 & 3.02 & 3.59
\end{tabular}
\end{ruledtabular}
\end{table}

Using Eq. \ref{eq.2L}, we have determined the $Q$-dependence of both $\Gamma_1$, and $\Gamma_2$, as summarized in Fig. \ref{fig.4}. The colored dashed lines  are the best model fits using the jump diffusion model,
\begin{equation}
\label{eq.tauJump}
\Gamma_i=\frac{D_i Q^2}{1+D\tau_{0i}Q^2}
\end{equation}
\noindent where $\tau_{0i}$ is the average residence time between jumps, and $D_i$ denotes the diffusion coefficient of process $i$. From these fits, we could reliably determine the characteristic relaxations for both processes, and the diffusion coefficient $D_2$ for the slower component. The convergence of $\Gamma_1$ to a plateau-like regime at low $Q$ complicates the determination of $D_1$.

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig8.eps}
\caption{(Color online) Simulated and calculated intrinsic intermediate scattering function $I_{in}(Q,t)$ of the confined water molecules at 280 K, and selected momentum transfer $Q$.  The measured decay component  is $I_{in}(Q,t)=e^{-(t/\tau_{KWW})^{\beta}}$ where $\tau_{KWW}$ and $\beta$ are the best fit parameters to the experimental data using  Eq. \ref{eq.IQ} with the KWW model.}
\label{fig.8}
\end{figure}

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig9.eps}
\caption{(Color online) Comparison of the simulated and measured $\langle \tau\rangle^{-1}$ at low $Q$. The average relaxation times shown were derived from the KWW model for consistency. The dashed lines are quadratic $Q^2$ fits to the simulated data.}
\label{fig.9}
\end{figure}

We have also evaluated the diffusion characteristics with the alternative KWW model discussed above. The extracted  average relaxation times are plotted as a function of $Q^2$ are shown in Fig. \ref{fig.5}. The dashed lines are fitted line using Eq. \ref{eq.tauJump}.  The fits however reveal different behavior. Specifically, the KWW fits indicate a diffusion process that goes from a jump-type diffusion at ambient temperature to a continuous one below 250 K. For this reason, we only compare the average relaxation time $\langle \tau_{KWW}\rangle$ with those obtained using the 2L model for $T$ between 250 K and 280 K. The extracted diffusion coefficients ($D_{KWW}$ and $D_2$) and average relaxation time $\langle\tau\rangle$ on the other hand are compared at all temperatures. These comparison are summarized in Figs. \ref{fig.6} and \ref{fig.7}. Data from bulk water \cite{Teixeira:85,Takahara:05} and SWNT \cite{Mamontov:06} are displayed for comparison, as well as the results from our molecular dynamics at low $Q$.  While the observed KWW diffusion parameter $D_{KWW}$ is a bit smaller than that reported for bulk water, the $D_2$ or slow diffusion coefficient for the narrow Lorentzian in the 2L model, is significantly smaller. This is not unreasonable since the slow process may be overshadowed in the KWW model by other faster processes. However, we find a much better agreement between the calculated and simulated $D$ with the KWW model, as evidenced in Fig. \ref{fig.6}.

Since a direct comparison between the simulated $Q$-dependent $\langle \tau_Q\rangle$  and the experimentally observed $Q$-independent $\langle \tau\rangle$ ( high $Q$-limit of the measured $\langle \tau_Q\rangle$ modeled with the jump diffusion model in Eq. \ref{eq.tauJump}) is not meaningful, the $Q$-dependent MD data are not shown in Fig. \ref{fig.7}. Instead, we chose to directly compare the simulated and measured $I(Q,t)$ and the corresponding $Q$-dependent  $\langle \tau_Q\rangle$ at each temperature.  To do this, we note that the simulations provide the intrinsic water dynamics while the neutron data contains both the dynamics and structure component. In order to adequately compare the intrinsic intermediate scattering function $I_{in}(Q,t)$, we show in Fig. \ref{fig.8} the simulated $I(Q,t)$ along with only the experimentally observed stretched decay component at 280 K (i.e. $e^{-(t/\tau_{KWW})^{\beta}}$ where $\tau_{KWW}$ is the fitted experimental value -- omitting the $EISF$ term). Reasonable agreement can be found between the two, particularly at the lowest $Q$ value.  We find some discrepancies in the faster decay at low times which would require further investigations. The long times show generally a reasonable agreement at these low $Q$  values,  which unfortunately degrades as $Q$ increases.   To highlight the level of agreement  at low $Q$ ( $\le$ 1.0 \AA$^{-1}$), we compare the simulated and experimentally observed $\langle \tau_{KWW}\rangle^{-1}$ in Fig. \ref{fig.9}.  The dashed lines are the corresponding $DQ^2$ fits from which the $D$ values from molecular dynamics (MD) (shown Fig. \ref{fig.6})  were determined.

\begin{figure}
\includegraphics[width=1.00\linewidth]{fig10.eps}
\caption{(Color online) Average relaxation time $\langle \tau \rangle$ of water confined in various microporous materials as a function of confining pore size at selected temperature of 240 K. The open symbols denote values observed for the hydrophilic silica-based (MCM-41S) materials in Ref. \cite{Liu:06}, and the filled symbols are for hydrophobic carbon-based materials, respectively highly ordered cabon molecular sieves CMK \cite{Chu:10}, cylindrical carbon nanotubes \cite{Mamontov:06}, and our current activated carbon ACF-10 fibers. }
\label{fig.10}
\end{figure}

\section{Conclusions} \label{sec:conc}

In summary, we have investigated the diffusion of water confined in a network of narrow wavy slits in activated carbon fiber by means of quasi-elastic neutron, and molecular dynamics. By  comparing the experimentally observed characteristic diffusion coefficients and relaxation times using the same analysis approach, we conclude that the diffusion of water in ACF-10 is slower than in bulk water but  of comparable magnitude to that in cylindrical carbon SWNT (only marginally smaller)  and other confining porous media of comparable pore size. Our main conclusion is that above 1 nm, it is not the geometry of the confining pores, but rather their dimensions that primarily affect the dynamics of confined water above 1 nm.  Stated differently, the diffusive dynamics of water in pores of the same size above 10 {\AA}, irrespective of whether they are cylindrical or not (slit or not) appears to be of the same order of magnitude for the temperature range investigated, as is illustrated for example in Fig. \ref{fig.10} for temperature $T=$240 K.   Data at other temperatures revealed similar behavior. To validate (or disprove) this perhaps fortuitous observation and evaluate its implication, future experimental work should systematically compare the effect of pore size on water dynamics in the complete series of ACF made from the same percursor (ACF-15, ACF-20 and ACF-25), to that of comparable hydrophilic silica samples (MCM-41 or other), all modeled using the same approach, since $\langle \tau\rangle$ values are known to be model-dependent. We expect however that MD simulations of water in hydrophobic and hydrophilic pores of varying pore size and geometry would yield predictive behavior.  A previous experimental report \cite{Chathoh:11} in which $\langle\tau\rangle$ values obtained from various samples using different models  (KWW or 2L) were compared, found no particular dependency of $\langle\tau\rangle$  on pore size.

The experimentally observed relaxation dynamics of confined water are supported by molecular dynamics  simulations of an ideal scenario in which water is restricted to diffuse within  the interstitial gap between two parallel graphene layers while in equilibrium with its aqueous bulk.  The simulations yield a reasonable agreement at low momentum transfer $Q$ ($Q\le1.0$ \AA${^{-1}}$).  The origin of the discrepancies at larger $Q$ remains to be clarified but could arise from either the relatively simple model used, the importance of localized dynamics or rotational motions, the presence of  oxygen-containing groups on the graphene surface or edge (carbonyl or hydroxyl for example).  Localized dynamics are strongly influenced by surface effects such as surface roughness \cite{Chialvo:14}, disorder and corrugation, which becomes dominant at high $Q$. The simulations yield however a diffusion coefficient $D$ that is in excellent agreement with the experimental value.  The comparison between QENS and simulation suggests the need for the additional interrogation of the effect of confined morphology, such as corrugation and pore connectivity, in order to aid the interpretation of the observed discrepancies in the relaxation times.

\acknowledgments
We thank R. Moody (SNS) for her help with the sample preparation, and R. Goyette (SNS) for his technical assistance at the beamline. This research was supported as part of the Fluid Interface Reactions, Structures and Transport (FIRST) center, an Energy Frontier Research Center funded by the U.S. Department of Energy, Office of Basic Energy Sciences.  Research at ORNL's SNS is sponsored by the Scientific User Facilities Division, Office of Basic Energy Sciences, U.S. Department of Energy.  The TEM measurements and analysis were performed at the ORNL's Center for Nanophase Materials Sciences, which is a DOE Office of Science User Facility.

{\footnotesize
$^*$\lq Kynol$^{TM}$ is a registered trademark of Gun Ei Chemical Industry Co., Ltd. for novoloid fibers and textiles.

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