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The development of a remote, synchronous general chemistry lab course, which was offered to 800 students in the fall semester of 2020, is described. The course was designed with similar curricular goals as our in-person lab course and featured chemistry kits developed by a team of faculty, staff, and graduate TAs. The kits, which were distributed via a rental program through the university bookstore, provided students the opportunity to conduct hands-on experiments at home or in their dorm room. To create the remote lab course, the team negotiated logistical and curricular issues such as finding alternatives to costly precision glassware and instrumentation, adding strategies for engaging students online, decreasing chemical hazards of experiments, and encouraging a safety culture for students working remotely. A professional development graduate course for TA instructors, associated with the general chemistry lab program, was also enhanced by including topics that were relevant for understanding remote learning environments. In redesigning the lab course for remote delivery, we developed new experiments (e.g., calibration), introduced new engagement strategies (e.g., badging), revised several experiments (e.g., heats of reaction), included an Arduino-based spectrometer (e.g., visible spectroscopy and pulse oximetry), and provided new student supports (e.g., TAs on-call). Survey data was gathered to assess student evaluation of the hands-on activities, the presence of synchronous TA help, the badging experience, the value of the lab course, and challenges faced in taking the lab course during a pandemic.

The degree of specific ventilatory heterogeneity (spatial unevenness of ventilation) of the lung is a useful marker of early structural lung changes which has the potential to detect early-onset disease. The Inspired Sinewave Test (IST) is an established noninvasive ‘gas-distribution’ type of respiratory test capable of measuring the cardiopulmonary parameters. We developed a simulation-based optimisation for the IST, with a simulation of a realistic heterogeneous lung, namely a lognormal distribution of spatial ventilation and perfusion. We tested this method in datasets from 13 anaesthetised pigs (pre and post-lung injury) and 104 human subjects (32 healthy and 72 COPD subjects). The 72 COPD subjects were classified into four COPD phenotypes based on ‘GOLD’ classification. This method allowed IST to identify and quantify heterogeneity of both ventilation and perfusion, permitting diagnostic distinction between health and disease states. In healthy volunteers, we show a linear relationship between the ventilatory heterogeneity versus age ($${R}^{2}=0.42$$ R 2 = 0.42 ). In a mechanically ventilated pig, IST ventilatory heterogeneity in noninjured and injured lungs was significantly different (p p

Extracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]

Richard M Bruce,1,2 Phi Anh Phan,2 Marzia Rigolli,3 Minh C Tran,2 Edmund Pacpaco,4 Najib M Rahman,4 Andrew D Farmery2 1Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK; 2Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; 3University of Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford, UK; 4Oxford University Hospitals NHS Foundation Trust, Oxford Centre for Respiratory Medicine, Oxford, UKCorrespondence: Richard M BruceKing’s College London, Shepherd’s House, Guy’s Campus, London, SE1 1UL, UKTel +44 20 7848 6324Email Richard.bruce@kcl.ac.ukBackground: There is marked variability in the symptoms and outcomes of patients with chronic obstructive pulmonary disease (COPD) which are poorly predicted by spirometry/FEV1%pred. Furthermore, as spirometry requires the performance of potentially distressing respiratory manoeuvres which are to some extent user-effort dependent, there is need for non-invasive and simple-to-perform techniques to identify subtypes of COPD which are more closely related to clinically relevant outcomes.Materials and Methods: The inspired sinewave test (IST) sinusoidally modulates the inspired concentration of a tracer gas (N2O) over successive tidal breaths. A single-compartment tidal-ventilation lung model processes the amplitude/phase of the expired N2O sinewave and estimates cardiopulmonary variables including: effective lung volume and indices of ventilatory heterogeneity (VH; ELV180/FRCpleth and ELV180/ELVpred). 83 COPD patients and 53 healthy controls performed the IST test, standard pulmonary function tests (Spirometry, body plethysmography and the single breath test of carbon monoxide uptake), and symptom severity questionnaires (COPD assessment test, CAT; mMRC dyspnoea-scale, mMRC-DS; Cough+Mucus score; C+M score).Results: ELV180/FRCpleth and ELV180/ELVpred were significantly lower in patients with COPD vs healthy participants (0.34± 0.11 vs 0.68± 0.14 and 0.7± 0.27 vs 0.98± 0.15, respectively; P< 0.05). Multivariable regression analysis demonstrated that ELV180/FRCpleth was a stronger and independent predictor of CAT, mMRC-DS and C+M score vs FEV1%pred. ELV180/ELVpred was a stronger and independent and better predictor of C+M score vs FEV1%pred. Phenotyping patients, based upon ELV180/ELVpred and FRC%pred, uncovered significant symptomatic differences between groups.Conclusion: The IST indices of VH were superior and independent predictors of symptom severity vs FEV1%pred and has potential as a non-invasive and simple-to-perform method to stratify patients into subgroups related to clinically relevant features of COPD.Keywords: COPD, lung function test, nitrous oxide, medical device, ventilatory heterogeneity

Mechanically and metabolically sensitive thin fibre (group III and IV) muscle afferents are activated during exercise, causing reflex cardiovascular responses that are essential to normal cardiovascular control. Impaired exercise performance in some disease states can be linked to abnormal muscle mechanoreflex and muscle metaboreflex activity. A role for this same afferent feedback in contributing to the hyperpnoea of exercise and the dyspnoea experienced by some patient groups on exercise has recently received increased attention. Evidence is summarised here that supports a role for muscle mechanoreflex and muscle metaboreflex involvement in the human ventilatory response to exercise and also their synergistic interaction with the central chemoreflex during muscular activity. The effects of local muscle training induced attenuation of the human muscle metaboreflex on this synergistic interaction and associated decrease in ventilation is discussed.

Objective The purpose of this study was to (1) examine the diagnostic utility of the King-Devick (KD) in professional ice hockey players and (2) determine whether the KD provides unique variance in predicting a diagnosis of concussion when given in combination with the SCAT-5. Study design Cohort Study. Setting Primary care. Patients/participants Professional ice hockey players. Independent variables Diagnosis versus no diagnosis of concussion. Main outcome measures King-Devick and SCAT-5 component scores. Methods In part 1, players suspected of having a concussion were evaluated at baseline and acutely with the KD and either the SCAT-3 or the SCAT-5. Players evaluated and not diagnosed with concussion served as active controls. In part 2, a separate group of players suspected of having a concussion was evaluated acutely with both the KD and SCAT-5. Results In part 1 of this study, 53 concussed players declined in performance on the KD from baseline to acute evaluation, whereas the performance of 76 active controls improved significantly. In part 2 of the study, 75 players were diagnosed with concussion and compared with 80 active controls who were evaluated and not diagnosed with concussion. Concussed players revealed a decline in KD performance from baseline to acute evaluation when compared with controls. However, the KD did not account for significant unique variance in predicting a diagnosis of concussion after accounting for SCAT-5 data. Conclusions The KD is useful in differentiating concussed and not concussed athletes acutely, but the KD does not seem to add additional diagnostic value over and above the SCAT-5.

Background Black men are disproportionately impacted by injuries in the United States. This disparity is glaring given that injury is one of the top ten causes of death. Injured Black men from disadvantaged neighborhoods experience higher injury mortality, years of life-expectancy loss, and psychological symptoms that persist after initial wounds have been treated. These injured men are typically transported to a hospital where they are medically stabilized and soon after are returned to the community. Black men are less likely to be discharged to comprehensive rehabilitation facilities, magnifying disparities in recovery from injury. While much research has examined individual characteristics that predict poor recovery from injury, fewer studies have focused on social and physical features of the environment and how they may impact the recovery of injury survivors. Purpose The purpose of this study was to describe Black men's perceptions of how characteristics of their environment affect their recovery following serious injury. Methods This was a secondary analysis of an existing data set consisting of semi-structured, qualitative interviews of 43 injured Black men in a northeastern city. The interviews were conducted three months following discharge from a large urban trauma center, and were audiotaped, transcribed verbatim, and de-identified. Thematic analysis consistent with the qualitative paradigm was used to identify themes. Results Four themes were identified in injured men's narratives: challenges to recovery, feeling unsafe, efforts to increase safety, and resources for recovery. Conclusions Our findings emphasize the importance of the role of community resources that can support injured men's recovery within their neighborhoods. Additional resources should be directed to survivors who return to disadvantaged communities after injury in order to minimize adverse emotional experiences that detract from recovery.

Introduction Medical device-related complications often lead to emergency department (ED) visits and hospitalizations for children with medical complexity (CMC), and pediatric complex care programs may be one way to decrease unnecessary encounters. Methods A retrospective cohort study comparing ED and inpatient encounters due to device complications of 2 cohorts of CMC at a single children's hospital during 2014-2016; 99 enrolled in a complex care program and 244 in a propensity-matched comparison group. Structured chart reviews identified ED and inpatient encounters due to device complications. The outcome was a change in the frequency of these encounters from the year before to the year after enrollment in the hospital's complex care program. Program effects were estimated with weighted difference-in-differences (DiDs), comparing the change in mean encounter frequency for CMC enrolled in the program with change for propensity-matched children not enrolled in the program. Results Mean encounters related to device complications decreased for both groups. Complication-related ED encounters per year decreased from a weighted mean (SD) of 0.74 (0.85) to 0.30 (0.44) in enrolled children and 0.26 (0.89) to 0.12 (0.56) in comparison children, a DiD of 0.30 fewer [95% confidence interval (CI) -0.01 to 0.60]. The largest reductions in device complication ED visits were among those with enteral tubes [0.36 fewer (95% CI 0.04-0.68)]. Hospitalizations decreased over time, but DiDs were not significantly different between groups. Conclusions Acute care use from device complications decreased with time. Complex care program enrollment may be associated with more substantial reductions in device complication ED visits, and effects may be most pronounced for CMC with enteral tubes.

BACKGROUND: Recent studies point to a fundamental distinction between population-based and individual-based anaesthetic pharmacology. At the population level, anaesthetic potency is defined as the relationship between drug concentration and the likelihood of response to a stimulus. At the individual level, even when the anaesthetic concentration is held constant, fluctuations between the responsive and unresponsive states are observed. Notably, these spontaneous fluctuations exhibit resistance to state transitions R(st). Therefore, the response probability in each individual depends not just upon the drug concentration, but also upon responses to previous stimuli. Here, we hypothesise that R(st) is distinct from drug potency and is differentially modulated by different anaesthetics. METHODS: Adult (14–24 weeks old) C57BL/6J male mice (n=60) were subjected to repeated righting reflex (RR) assays at equipotent steady-state concentrations of isoflurane (0.6 vol%), sevoflurane (1.0 vol%), and halothane (0.4 vol%). RESULTS: Fluctuations in RR were observed for all tested anaesthetics. Analysis of these fluctuations revealed that R(st) was differentially modulated by different anaesthetics (F[2, 56.01]=49.59; P

New findings What is the topic of this review? In this review, we examine the evidence for control mechanisms underlying exercise hyperpnoea, giving attention to the feedback from thin-fibre skeletal muscle afferents, and highlight the frequently conflicting findings and difficulties encountered by researchers using a variety of experimental models. What advances does it highlight? There has been a recent resurgence of interest in the role of skeletal muscle afferent involvement, not only as a mechanism of healthy exercise hyperpnoea but also in the manifestation of breathlessness and exercise intolerance in chronic disease. Abstract The ventilatory response to dynamic submaximal exercise is immediate and proportional to metabolic rate, which maintains isocapnia. How these respiratory responses are controlled remains poorly understood, given that the most tightly controlled variable (arterial partial pressure of CO2 /H+ ) provides no error signal for arterial chemoreceptors to trigger reflex increases in ventilation. This review discusses evidence for different postulated control mechanisms, with a focus on the feedback from group III/IV skeletal muscle mechanosensitive and metabosensitive afferents. This concept is attractive, because the stimulation of muscle mechanoreceptors might account for the immediate increase in ventilation at the onset of exercise, and signals from metaboreceptors might be proportional to metabolic rate. A variety of experimental models have been used to establish the contribution of thin-fibre muscle afferents in ventilatory control during exercise, with equivocal results. The inhibition of afferent feedback via the application of lumbar intrathecal fentanyl during exercise suppresses ventilation, which provides the most compelling supportive evidence to date. However, stimulation of afferent feedback at rest has no consistent effect on respiratory output. However, evidence is emerging for synergistic interactions between muscle afferent feedback and other stimulatory inputs to the central respiratory neuronal pool. These seemingly hyperadditive effects might explain the conflicting findings encountered when using different experimental models. We also discuss the increasing evidence that patients with certain chronic diseases exhibit exaggerated muscle afferent activation during exercise, resulting in enhanced cardiorespiratory responses. This might provide a neural link between the well-established limb muscle dysfunction and the associated exercise intolerance and exertional dyspnoea, which might offer therapeutic targets for these patients.

Background High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events. Methods This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission. Results Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups. Limitations Assessment of feeding exposure did not account for quantity and duration. Discussion Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

In this "Women in GRSS" column, we highlight the roles of women in organizing some IEEE Geoscience and Remote Sensing Society (GRSS) summer training programs this year as well as the upcoming 2020 IEEE International Geoscience and Remote Sensing Symposium (IGARSS) that is in preparation for next year. Organizing a summer training program or an international scientific conference is a major undertaking, but it can also be a professionally enriching and personally rewarding activity. For this issue of IEEE Geoscience and Remote Sensing Magazine (GRSM), we highlight the roles of IEEE Women in Engineering (WIE) in terms of these important GRSS training and scientific conferences.

NEW FINDINGS What is the central question of this study? Classically, the stimulation of thin-fibre skeletal muscle afferents, via the application of postexercise circulatory occlusion (PECO) at rest, fails to generate ventilatory responses. We used a new experimental protocol to examine whether the involvement of these metabosensitive afferents in ventilatory control can only be revealed during exercise, when other potentially synergistic inputs that increase central respiratory drive are activated. What is the main finding and its importance? We found that PECO of one leg augmented the ventilatory and heart rate responses to single-legged exercise of the contralateral leg, suggesting that metaboreceptive muscle afferents contribute to the control of the exercise hyperpnoea. ABSTRACT Inhibition of thin-fibre skeletal muscle afferent neurotransmission attenuates ventilatory and cardiovascular responses to exercise. However, stimulation of muscle metaboreceptive afferents at rest, via postexercise circulatory occlusion (PECO), classically fails to generate increases in ventilation or heart rate. It is possible that the involvement of muscle afferent feedback in ventilatory control can only be revealed during exercise, when other potentially synergistic inputs that increase central respiratory drive are activated. Therefore, we assessed the cardiorespiratory responses to single-legged cycling exercise with or without PECO of the contralateral leg. Thirteen healthy participants performed left-legged cycling exercise (40 or 60 W) followed by either: (i) no PECO (Con trial); or (ii) PECO (PECO trial) of the left leg for 3 min. During this 3 min period, right-legged cycling exercise was performed at the same workload as the preceding left-legged exercise (40 or 60 W). During 60 W right-legged cycling, ventilation relative to baseline was significantly higher in the PECO versus Con trial (22.9 ± 2 versus 18.7 ± 1.8 l min-1 ; P

Purpose To test the hypothesis that the anatomic correlate of the gray optic disc crescent is pigmentation of externally oblique border tissue of Elschnig. Design Retrospective study. Participants African-American adult men with or without clinically apparent gray optic disc crescents. Methods McNemar's test for paired data and kappa statistic with 95% confidence intervals were used to examine the relationships between eyes with or without gray optic disc crescents and corresponding spectral-domain (SD) OCT images with enhanced depth imaging (EDI). Main Outcome Measures Correlation between clinical gray optic disc crescents and hyperreflectivity of externally oblique border tissue of Elschnig by SD OCT with EDI. Results Twenty-five eyes had clinically apparent gray optic disc crescents, of which SD OCT with EDI revealed hyperreflectivity (interpreted as increased pigmentation) of externally oblique (obtuse angle) border tissue of Elschnig in 22 eyes, that is, extending into Bruch's membrane opening and presumably visible by funduscopy. Thirty-two eyes from matched participants had no apparent gray optic disc crescent, of which SD OCT with EDI revealed hyperreflectivity of the border tissue of Elschnig in 23 eyes, but with a nonoblique (right angle) or internal (acute angle) angle, which would presumably obstruct funduscopic visualization. Conclusions Observations by SD OCT with EDI suggest that the anatomic correlate of the gray optic disc crescent is pigmentation of externally oblique border tissue of Elschnig.

Establishing whether speech and language therapy after stroke has beneficial effects on speaking ability is challenging because of the need to control for multiple non-therapy factors known to influence recovery. We investigated how speaking ability at three time points post-stroke differed in patients who received varying amounts of clinical therapy in the first month post-stroke. In contrast to prior studies, we factored out variance from: initial severity of speaking impairment, amount of later therapy, and left and right hemisphere lesion size and site. We found that speaking ability at one month post-stroke was significantly better in patients who received early therapy (n = 79), versus those who did not (n = 64), and the number of hours of early therapy was positively related to recovery at one year post-stroke. We offer two non-mutually exclusive interpretations of these data: (1) patients may benefit from the early provision of self-management strategies; (2) therapy is more likely to be provided to patients who have a better chance of recovery (e.g., poor physical and/or mental health may impact suitability for therapy and chance of recovery). Both interpretations have implications for future studies aiming to predict individual patients' speech outcomes after stroke, and their response to therapy.

Traditional smart home (SH) technology combined with new monitoring technologies designed to prevent falls and detect health status changes is the current direction for SH development. The combination of conventional SH technology with healthcare technology is likely to be an effective approach to preventing nursing home placement for frail older adults. Barriers to adopting or implementing monitoring technology include concerns about privacy and reluctance of older adults to accept the technology. Acceptance of the monitoring technology depends not only on the older persons’ health and functional status but also upon the perception of need and personal goals. Since great variability of health and disability conditions exists among community-dwelling older adults, their purposes of using SH with healthcare technologies may also be diverse depending on their levels of physical and cognitive functions and severity of illnesses. Older adults and their informal caregivers are likely to insist on choice of technologies suitable for their goals. Health care providers need to be familiar with the available technology. Home-based technologies allow older persons to adapt to changing physical and cognitive function and preserve living in a familiar environment within an established social network. Home-based technologies may be most effective, if they also promote healthy behaviour and lifestyles for continued community living. Focusing on the situation in the United States, this chapter includes: (1) a description of societal needs for the technology, (2) a summary of current SH status, (3) a review of older adults’ perceptions of SH, healthcare technologies and their effectiveness, (4) caregivers’ perspectives of the technology, and (5) defining the role of SH with health care technologies in the Model toward Optimal Management for Independent through Technological Adoption (Tomita et al., 2009). The model expands on behavioural medicine to promote healthy behaviours in community-dwelling older adults.

Background Several devices record and interpret patient brain activity via electroencephalogram (EEG) to aid physician assessment of anaesthetic effect. Few studies have compared EEG monitors on data from the same patient. Here, we describe a set-up to simultaneously compare the performance of three processed EEG monitors using pre-recorded EEG signals from older surgical patients. Methods A playback system was designed to replay EEG signals into three different commercially available EEG monitors. We could then simultaneously calculate indices from the SedLine® Root (Masimo Inc., Irvine, CA, USA; patient state index [PSI]), bilateral BIS VISTA™ (Medtronic Inc., Minneapolis, MN, USA; bispectral index [BIS]), and Datex Ohmeda S/5 monitor with the Entropy™ Module (GE Healthcare, Chicago, IL, USA; E-entropy index [Entropy]). We tested the ability of each system to distinguish activity before anaesthesia administration (pre-med) and before/after loss of responsiveness (LOR), and to detect suppression incidences in EEG recorded from older surgical patients receiving beta-adrenergic blockers. We show examples of processed EEG monitor output tested on 29 EEG recordings from older surgical patients. Results All monitors showed significantly different indices and high effect sizes between comparisons pre-med to after LOR and before/after LOR. Both PSI and BIS showed the highest percentage of deeply anaesthetised indices during periods with suppression ratios (SRs) > 25%. We observed significant negative correlations between percentage of suppression and indices for all monitors (at SR >5%). Conclusions All monitors distinguished EEG changes occurring before anaesthesia administration and during LOR. The PSI and BIS best detected suppressed periods. Our results suggest that the PSI and BIS monitors might be preferable for older patients with risk factors for intraoperative awareness or increased sensitivity to anaesthesia.

Background : The Modified Fatigue Impact Scale (MFIS) is one of the most common self-report measures used to assess fatigue in multiple sclerosis (MS). Despite its widespread use, there are no existing normative data for the MFIS. Objective The present investigation aimed to develop normative data for the MFIS in a large community sample, stratified by age, gender, and education and to compare the derived new cutoffs to an existing cutoff. Methods A total of 675 healthy individuals, stratified by age, gender, and education completed the MFIS. After the removal of 19 outliers, the final sample consisted of 656 individuals. Archival data of 540 individuals with MS who completed the MFIS were also included to analyze the utility of the new cutoffs. Results There were no main effects on the MFIS for gender. However, there were main effects for age and education. Specifically, younger cohorts (25-34 and 35-44) reported less physical fatigue compared to the two oldest cohorts (55-64 and 65-74). Similar effects were found for total MFIS fatigue with individuals aged 55-64 reporting greater overall fatigue than 35-44 year olds. Finally, 18-24 year olds reported significantly higher levels of cognitive fatigue compared to 35-44 and 65-74 aged cohorts. No other effects were observed for age. Individuals with higher education consistently reported less fatigue. Subsequent analyses also revealed an interaction effect for age x gender. When examining the age x gender interaction, women age 18-24 reported significantly greater levels of physical, cognitive, psychosocial, and total fatigue than their male counterparts. In contrast, men aged 65-74 reported greater physical, cognitive, and total fatigue than women their age. Comparisons of the existing cutoff of the MFIS to the new age, gender, and education specific cutoffs found either comparable or slightly higher rates of fatigue with the latter. Conclusion Based on these findings, updated normative data and age, gender, and education specific cutoffs are provided. Utilization of these updated norms will result in a more accurate assessment of fatigue and will be valuable for those conducting research and/or clinical practice with individual with MS.

Lifestyle interventions to increase exercise and improve diet have been the focus of recent clinical trials to potentially prevent Alzheimer’s disease (AD) [1,2]. However, despite the strong links between sleep disruptions, cognitive decline, and AD, sleep enhancement has yet to be targeted as a lifestyle intervention to prevent AD. A recent meta-analysis suggests that approximately 15% of AD may be prevented by an efficacious intervention aimed to reduce sleep disturbances and sleep disorders [3]. Chronic insomnia is the most frequent sleep disorder occurring in at least 40% of older adults [4]. Individuals with insomnia are more likely to be diagnosed with Alzheimer’s Disease (AD) [5,6] and demonstrate decline in cognitive function [7] at long-term follow-up. AD is characterized by the accumulation of amyloid-β (Aβ) plaques and tau tangles in the brain, and growing evidence shows impaired sleep contributes to the accumulation of Aβ [8–10]. An intervention aimed at improving insomnia may be a critical opportunity for primary prevention to slow cognitive decline and potentially delay the onset of AD. Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious treatment for insomnia [11–14], but the use of CBT-I to improve cognitive function and potentially reduce the rate of Aβ accumulation has never been examined. Therefore, the objective of the proposed study is to examine the efficacy of CBT-I on improving cognitive function in older adults with symptoms of insomnia. An exploratory aim is to assess the effect of CBT-I on rate of Aβ accumulation.

Background Traumatic injury is not evenly distributed across race and class in America. Black men are marginalized in society, often live in disadvantaged neighborhoods, and are at higher risk for injury mortality and ongoing physical and psychological problems following injury, including post-traumatic stress disorder (PTSD) and depression. While much research has examined individual factors associated with increased post-injury psychological symptoms, the contribution of the social and physical environment has been relatively-understudied. Purpose The purpose was to examine the contribution of neighborhood characteristics to PTSD and depressive symptom severity in Black men following serious injury. Methods A secondary analysis of 451 seriously injured men living in Philadelphia were drawn from a prospective cohort study. Study participants were linked by a geographic information system (GIS) to characteristics in their neighborhood in order to spatially model the factors that contribute to increased psychological symptom severity at 3 months post-injury. Factor analysis identified underlying constructs of 32 neighborhood predictors, which were entered in a generalized estimating equation (GEE) regression analysis. Covariates included mechanism of injury, severity of injury, age, and health insurance. Results Neighborhood characteristics loaded onto 4 constructs: neighborhood disconnectedness; concentrated disadvantage; crime, violence, and vacancy; and race/ethnicity. Higher PTSD symptom severity was reported by 36.8% and associated with neighborhood crime, violence, and vacancy, and higher depressive symptom severity was reported by 30.4% and associated with neighborhood disconnectedness. Both PTSD and depressive symptoms were associated with intentional mechanisms of injury, such as gunshot wounds, stabbing, and assault; and with having Medicaid or no insurance. Higher severity of injury was associated with depressive symptoms. Conclusions Findings suggest that neighborhood characteristics such as neighborhood disconnectedness and crime, violence, and vacancy have measurable associations with psychological symptoms after injury. The evidence supports the need for interventions to improve post-injury mental health by modifying the urban environment.

Background The Symbol Digit Modalities Tests (SDMT) is the most sensitive measure to multiple sclerosis (MS)-related cognitive dysfunction. However, existing normative data has been under scrutiny. Specifically, they are outdated, do not take into account gender, and are poorly stratified by education. More importantly, there exists no oral only version norms, which is typical administration among individuals with MS. Objective The present investigation aimed to develop updated normative data of the oral version SDMT in which age, gender, and education were taken into consideration. Methods A total of 675 healthy individuals, stratified by age, gender, and education completed the oral version SDMT. Results Significant effects were found for age, gender, and education, consistent with previous contentions. Specifically, performance on the SDMT tends to decline with age, with the most noticeable decline beginning in the third decade of life and continuing into the sixth decade. Women, in general perform better than men, with an average of 5.1 more points. Finally, education effects were apparent among those aged 25–54. Conclusion Based on these findings, updated normative data are provided. Utilization of these updated norms will result in a much needed and more accurate assessment of processing speed for individuals with MS.

Multiple sclerosis (MS) is an autoimmune disease that causes a range of problematic symptoms. These symptoms tend to get worse over time, causing substantial impairment in patient quality of life. Although many effective disease-modifying therapies (DMTs) exist that slow the course of MS, patients often do not choose to take them, which may be because these medications carry substantial risks of side effects, varying from mild to severe, while only decreasing the probability of future symptoms. In the current study, we examined MS patients' self-reported likelihood of taking medications with a range of efficacies (11 values, ranging from 0.1% to 99.9%), side-effect probabilities (11 values, ranging from 0.1% to 99.9%), and side-effect severities (mild, moderate, or severe). These data were well-described by a three-dimensional probability-discounting model that isolated patients' undiscounted likelihood of taking DMTs, as well as their discounting and psychophysical scaling/weighting of side-effect probabilities and efficacy. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

OBJECTIVE Although the effectiveness and risks of multiple sclerosis (MS) therapies are established, relatively little is known about how these benefits and risks are perceived and weighed by patients. This risk-benefit trade-off is important for clinicians, industry, and regulators to consider when determining which therapies to develop, approve for clinical use, and recommend to individual patients. The primary objective of the present study was to describe individual differences in how MS patients weigh risks and benefits when making treatment decisions. METHOD Two hundred ninety patients with MS completed tasks assessing their willingness to take a hypothetical disease-modifying therapy (DMT) at varying levels of efficacy, side effect probability, and side effect severity. Patients also completed questionnaires assessing MS knowledge, medication beliefs, health care climate, and disease severity. RESULTS Patients with a primary progressive course reported increased DMT willingness compared to patients with relapsing-remitting and secondary progressive courses. Patients were less willing to initiate a DMT across a range of efficacies and side effects if they had never taken a DMT, reported more complementary and alternative health beliefs, or reported a history of discontinuing DMTs due to side effects. More MS knowledge was associated with more willingness to initiate a DMT. CONCLUSIONS The results represent an initial step in understanding how patients with chronic disease balance the risks and benefits of medication initiation. Extension of this research may have implications for pharmaceutical development, physician-patient interaction, adherence intervention, and disease education. (PsycINFO Database Record

Background : The Symbol Digit Modalities Test (SDMT) has been recommended for use in clinical trials and outcome studies to monitor cognitive change. However, defining what is a meaningful change has been elusive for several years. Objective : The present investigation aimed to develop methods for assessing individual-level statistically significant change on the SDMT - reliable change indices (RCIs) and standardized regression-based (SRB) equations. Methods : A total of 219 healthy individuals completed the oral version SDMT at baseline, 6-month and 1-year follow-up. Results : The SDMT demonstrated high reliability across all time points (r's = .83 to .86). Reliable change scores of 7, 8, and 10 points for the 6-month intervals represented statistically meaningful change at the .70, .80, and .90 confidence intervals, respectively. Over 1-year, a difference of 8, 10, and 12 was statistically meaningful at the .70, .80, and .90 confidence intervals, respectively. SRB equations are also provided taking into account additional factors found to be predictive of SDMT scores over time. Conclusion : Clinicians frequently denote a decline of 4 points on the SDMT as meaningful. Results in this large normative sample show that higher cut-points are needed to demonstrate statistically significant decline at the individual level. RCIs are provided for 6 month and one year assessment, which is typical in clinical practice and trials. SRB equations are also provided for use when applicable and may provide a more precise assessment of meaningful change.

Weight loss improves overall health, and reduces inflammation, risk of stroke, heart attack, diabetes, certain cancers, and death among individuals with obesity. Weight loss also improves mobility, increases stamina, and elevates mood. Between 25 and 33% of people with Multiple Sclerosis (pwMS) have obesity. Multiple Sclerosis (MS) and obesity are independently associated with reduced mobility, increased fatigue, and depression. Most behavioral weight loss trials exclude individuals with neurologic disease. Consequently, few studies have examined the effects of weight loss on symptom presentation and health outcomes among pwMS and obesity. This is the first study examining the efficacy of a comprehensive behavioral weight loss intervention designed specifically for pwMS. The purpose of this study is to develop and assess the efficacy of a telehealth administered weight loss intervention tailored for pwMS. Additionally, we aim to determine if weight loss reduces physical and emotional symptoms in individuals with obesity and MS. We will enroll 70 pwMS in a wait-list crossover trial to examine the efficacy of our intervention. If successful, findings will help determine whether we can help participants lose clinically significant weight - and whether weight loss among pwMS and overweight/obesity reduces fatigue, and improves mobility, mood, and quality of life.

Although effective disease-modifying treatments (DMTs) are available for individuals suffering from multiple sclerosis (MS), many patients fail to take their recommended medications. Unlike medications that provide immediate relief from existing symptoms, DMTs decrease the probability of future symptoms (i.e., a probabilistic benefit) while concurrently carrying an appreciable risk of immediate side effects (i.e., a probabilistic cost). Prior research has shown that both the probability of reducing disease progression and the probability of experiencing side effects impact patients' likelihood of taking a hypothetical DMT. The role that side effect severity plays in treatment decisions remains unexplored. The present study examined how probability of medication efficacy and side effect severity impact patients' likelihood of taking hypothetical DMTs. Patients' likelihood of taking a DMT systematically decreased as medication efficacy decreased and side effect severity increased. Because side effect severity appears to impact decision-making processes in unique ways, the present results suggest that providers should present information on severe (which are typically rare) and mild to moderate side effects (which are more common) separately. (PsycINFO Database Record

Background: Understanding the relationship between perceived fatigue and performance fatigability could lead to more effective interventions to manage multiple sclerosis (MS)–related fatigue. However, the relationship between self-perceived fatigue measured using the Neurological Fatigue Index (NFI-MS) and performance fatigability in people with MS is unknown. We sought to explore the relationship between the NFI-MS and performance fatigability in people with MS. Methods: Fifty-two participants (mean ± SD age, 46.8 ± 10.1 years) completed the study. Three measures of performance fatigability were used: percent change in meters walked from first to last minute of the 6-Minute Walk Test, percent change in force exerted from first to last trial on a repetitive maximal hand grip test, and response speed variability on the Continuous Performance Test. Perceived physical and cognitive fatigue were measured using the NFI-MS. The state level of fatigue was examined immediately before and after performing the fatigability measures using a one-item visual analogue fatigue scale. Results: Of the three performance fatigability measures, only the attentional task (response speed variability) was significantly associated with NFI-MS physical (r = 0.326, P = .020) and cognitive (r = 0.276, P = .050) domain scores. Participants demonstrated significantly higher state levels of fatigue after performing all performance fatigability measures (P ≤ .001). Conclusions: The NFI-MS and the performance fatigability measures used in this study are easy to administer. We encourage wider use of these measures in clinical and research settings for comprehensive assessment of MS-related fatigue.

BackgroundLittle research examines how to best identify concussed athletes. The purpose of the present study was to develop a preliminary risk decision model that uses visible signs (VS) and mechanisms of injury (MOI) to predict the likelihood of subsequent concussion diagnosis.MethodsCoders viewed and documented VS and associated MOI for all NHL games over the course of the 2013–2014 and 2014–2015 regular seasons. After coding was completed, player concussions were identified from the NHL injury surveillance system and it was determined whether players exhibiting VS were subsequently diagnosed with concussions by club medical staff as a result of the coded event.ResultsAmong athletes exhibiting VS, suspected loss of consciousness, motor incoordination or balance problems, being in a fight, having an initial hit from another player’s shoulder and having a secondary hit on the ice were all associated with increased risk of subsequent concussion diagnosis. In contrast, having an initial hit with a stick was associated with decreased risk of subsequent concussion diagnosis. A risk prediction model using a combination of the above VS and MOI was superior to approaches that relied on individual VS and associated MOI (sensitivity=81%, specificity=72%, positive predictive value=26%).ConclusionsCombined use of VS and MOI significantly improves a clinician’s ability to identify players who need to be evaluated for possible concussion. A preliminary concussion prediction log has been developed from these data. Pending prospective validation, the use of these methods may improve early concussion detection and evaluation.

BackgroundEarly identification and evaluation of concussions is critical. We examined the utility of using visible signs (VS) of concussion in predicting subsequent diagnosis of concussion in NHL players.MethodsVS of concussion were identified through video review. Coders were trained to detect and record specific visual signs while viewing videos of NHL regular season games. 2460 games were reviewed by at least two independent coders across two seasons. The reliability, sensitivity and specificity of these VS were examined.ResultsVS were reliably coded with inter-rater agreement rates ranging from 73% to 98.9%. 1215 VS were identified in 861 events that occurred in 735 games. 47% of diagnosed concussions were associated with a VS but 53% of diagnosed concussions had no VS. Of the VS, only loss of consciousness, motor incoordination, and blank/vacant look had positive likelihood ratios greater than 1, indicating a positive association with concussion diagnoses. Slow to get up and clutching of the head were observed frequently but had low positive predictive values. Sensitivity decreased and specificity increased when multiple VS occurred together.ConclusionsNon-medical personnel can be trained to reliably identify events in which VS occur and to reliably identify specific VS within each of those events. VS can be useful to detect concussion early but they are not enough since more than half of physician diagnosed concussions occurred without the presence of a visual sign. The results underscore the complexity of this injury and highlight the need for comprehensive approaches to injury detection.

A coordinated project has been underway to improve computational fluid dynamics predictions of slender airframe aerodynamics. The work is focused on two flow conditions and leverages a unique flight data set obtained with an F-16XL aircraft. These conditions, a low-speed high angle-of-attack case and a transonic low angle-of-attack case, were selected from a prior prediction campaign wherein the computational fluid dynamics failed to provide acceptable results. In this paper, the background, objectives, and approach to the current project are presented. The work embodies predictions from multiple numerical formulations that are contributed from multiple organizations, and the context of this campaign to other multicode, multi-organizational efforts is included. The relevance of this body of work toward future supersonic commercial transport concepts is also briefly addressed.

Background Fatigue is prevalent in Multiple Sclerosis (MS), but little research indicates how to best quantify changes in fatigue over time. Objective Evaluate reliable change on the abbreviated Modified Fatigue Impact Scale (MFIS-5) in MS patients. Methods One-hundred sixty eight MS patients completed the MFIS-5 at baseline and follow-up as part of two larger studies. Test-retest reliability scores and reliable change indices were calculated. Results Differences of 4, 5, 6, and 7 points on the MFIS-5 represent statistically meaningful change at the .70, .80, .90, and .95 confidence intervals, respectively. Conclusions The MFIS-5 can be used to quickly and reliably assess statistically meaningful changes in fatigue among MS patients.

BACKGROUND AND OBJECTIVES: Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing. METHODS: This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient’s family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure. RESULTS: During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25–95) to 43 (interquartile range: 24–88) hours (both P CONCLUSIONS: The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.

Intravenous anesthetic agents are associated with cardiovascular instability and poorly tolerated in patients with cardiovascular disease, trauma, or acute systemic illness. We hypothesized that a new class of intravenous (IV) anesthetic molecules that is highly selective for the slow type of γ-aminobutyric acid type A receptor (GABA(A)R) could have potent anesthetic efficacy with limited cardiovascular effects. Through in silico screening using our GABA(A)R model, we identified a class of lead compounds that are N-arylpyrrole derivatives. Electrophysiological analyses using both an in vitro expression system and intact rodent hippocampal brain slice recordings demonstrate a GABA(A)R-mediated mechanism. In vivo experiments also demonstrate overt anesthetic activity in both tadpoles and rats with a potency slightly greater than that of propofol. Unlike the clinically approved GABAergic anesthetic etomidate, the chemical structure of our N-arylpyrrole derivative is devoid of the chemical moieties producing adrenal suppression. Our class of compounds also shows minimal to no suppression of blood pressure, in marked contrast to the hemodynamic effects of propofol. These compounds are derived from chemical structures not previously associated with anesthesia and demonstrate that selective targeting of GABA(A)R-slow subtypes may eliminate the hemodynamic side effects associated with conventional IV anesthetics.

Background Reliably monitoring changes in fatigue is an ongoing concern. Objective Evaluate reliable change using the Modified Fatigue Impact Scale 5-item version (MFIS-5) in people with MS (PwMS). Methods The MFIS-5 was administered at three time points in 157 PwMS. Test-retest reliability and reliable change scores were calculated at the 0.70, 0.80, 0.90, and 0.95 confidence intervals. Results Difference scores of 3, 4, 5, and 6 represent statistically meaningful change at the 0.70, 0.80, 0.90, and 0.95 confidence intervals, respectively. Conclusion Cut points derived from this study and prior work can help reliably assess changes in fatigue over time.

Background The Expanded Disability Status Scale (EDSS) measures disease progression in Multiple Sclerosis (MS). EDSS changes are assumed to be due to worsening MS-related disability. Strict interpretation of this premise may include some normal findings as abnormal, inflating the disability score. Further, determining the cause of neurologic symptoms can be difficult in an older population with comorbid illness and polypharmacy. Objective To examine the association between EDSS, age, comorbidities and polypharmacy. Methods 106 people, 55 years and older, with and without MS were administered the EDSS and a validated comorbidity questionnaire. Polypharmacy was also assessed. Results Median EDSS scores were 6.0 in people with MS and 3.0 in people without MS. No participant in our cohort had an EDSS of 0. Higher EDSS scores were associated with older age and more polypharmacy. Pyramidal and cerebellar functional systems accounted for the largest percentage of unique variance between groups. Conclusion Older individuals with and without MS demonstrated significant disability on the EDSS. These findings indicate that EDSS scores may be partially due to factors other than MS. Our understanding of disease course and disability may benefit from the development of normative EDSS scores to correct for these factors.