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HighlightsThe influence of moisture content and fine levels on the angle of repose (AoR) was evaluated for multiple pellet types.Filling angle of repose (AoR) show some increases with moisture, but values remained in the “free-flowing” range.Emptying and tilting table AoR were more impacted by additional moisture and fines.Image analysis was successfully used to measure the angle of repose.Abstract. Biomass and feed pellets can be handled and stored using similar equipment to that used for other bulk materials; however, their unique physical characteristics can lead to handling challenges. Understanding the flow characteristics of these materials is essential for handling and storage system design, but these characteristics are not well defined in less-than-ideal conditions. The overall objective of this study was to evaluate how moisture content and level of fines influence the angle of repose (AoR) of hardwood, pine bedding, and feed pellets. Three moisture levels (unconditioned, two and four percentage points above equilibrium) and four particle fine levels (0%, 5%, 10%, and 15% fines) were evaluated. Multiple methods for measuring AoR were assessed, including the fixed funnel (both lose and confined base), tilting table, and a clear-sided test fixture to measure emptying and filling AoR simultaneously. An image analysis tool using a polyline fit to the pellet boundary was developed and used to measure the respective angles. The impact of increasing moisture and fine levels varied by pellet type and AoR measurement method, but generally resulted in an increase in AoR. The filling (dynamic) AoR was least impacted by moisture and fine levels, showing no differences among fine levels, and limit differences among moisture levels. Emptying (static) AoR was linearly correlated with the tilting table method, but the tilting table AoR was on average 15.5° higher. Utilizing the combined test fixture, the overall filling (dynamic) AoR for hardwood, pine bedding, and feed pellets inclusive of all moisture contents and percent fine levels were 33.8°, 35.0°, and 35.4°, respectively, while emptying (static) AoR’s were 39.9°, 44.2°, and 42.7°. Keywords: Angle of repose, Biomass, Moisture content, Particle size, Pellets, Physical properties.

BACKGROUND: Among patients facing lower extremity amputation due to dysvascular disease, mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during pre-operative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS: Semi-structured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation level decisions. RESULTS: We interviewed 22 patients and 21 surgeons and physicians and identified three themes related to conversations around mortality: 1) both patients and providers report that mortality conversations are not common prior to amputation; 2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and 3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS: Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.

To determine gender disparities and potential factors that modify prosthesis prescription practices in veteran patients who have undergone their first major unilateral amputation due to diabetes or peripheral arterial disease. A retrospective cohort study using the VA Corporate Data Warehouse to compare prosthesis prescription rates and time to prescription between men and women veterans. The primary exposure was gender. The primary outcome was a qualifying prosthesis prescription within 12 months of the incident amputation. The secondary outcome was time to prosthesis prescription. Multiple logistic and linear regression was used to control for potential confounders and identify potential effect modification. 2,862 individuals met study criteria, with 1690 (60%) prescribed a qualifying prosthesis. Men were more likely to receive a prosthesis prescription than women (59% versus 45%, respectively; p = 0.03). This difference was observed primarily among those with a diagnosis of major depressive disorder. In this subgroup, the odds of men receiving a prosthesis over women was over 3 times (adjusted odds ratio = 3.3; 95% Confidence Interval, 1.5, 7.4). Men had a mean shorter time to prescription compared to women (112 ± 72 versus 136 ± 79 days, respectively, p = 0.08). Depression in women negatively impacts their prosthesis prescription rates and time to prescription compared to men. This disparity may have significant impacts on future function and quality of life.Implications for RehabilitationThis study found that men more commonly received a prosthesis prescription and received it earlier than women.This disparity was most extreme among women who had been diagnosed with major depressive disorder.Providers should identify at risk patients early and consider targeted interventions to address depression during the preoperative and immediate postoperative phases.Future research should continue to work to identify gender-specific needs that exacerbate disparity. This study found that men more commonly received a prosthesis prescription and received it earlier than women. This disparity was most extreme among women who had been diagnosed with major depressive disorder. Providers should identify at risk patients early and consider targeted interventions to address depression during the preoperative and immediate postoperative phases. Future research should continue to work to identify gender-specific needs that exacerbate disparity.

HighlightsThe predicted bulk density of two wheat varieties varied with drop height, similar to the experiments.The percentage composition of three kernel size fractions in the wheat varieties affected the bulk density.Accurate particle shape representation simulated the heap profile better but required longer computational time.The single-sphere model is more practical to use because of its higher accuracy and lower computational cost.Abstract. Grain bulk density varies widely depending on kernel properties and handling practices. The discrete element method (DEM) can model such behavior at the particle level, including wide-ranging interactions with equipment. The objective of this study was to develop a DEM model to predict wheat bulk density as affected by grain drop height and kernel size distribution. The bulk density of two wheat varieties was measured experimentally for a range of drop heights with a modified test weight per bushel apparatus and was simulated in EDEM v2018.1 using single-sphere and five-sphere particle models that accounted for three kernel size fractions. For both particle models, simulations matched the observed behavior, showing a bulk density increase with increasing drop height and bulk density differences between varieties due to different kernel size fractions. The single-sphere particle model predicted the bulk density with higher accuracy than the five-sphere particle model, while the five-sphere model, which more accurately represented the shape of wheat kernels, allowed better simulation of the heap profile at the cost of longer computation time. These particle models can be used to simulate bulk density of wheat under compaction and to improve prediction models of grain pack factor for wheat. Keywords: Bulk density, DEM, Drop height, Size distribution, Wheat.

HighlightsComputational fluid dynamics modeling of airflow through the peanut load improved the design process.Peanuts dried using the modified hopper bottom semi-trailer passed inspection at 9.1% moisture content in preliminary tests.Final moisture gradient in the modified hopper bottom semi-trailer consisted of even layers from front-to-back with moisture increasing with depth.Current inspection probe sampling pattern biases inspection moisture measurements lower by not sampling the hopper bottom.Abstract. Hopper bottom semi-trailers (HBST) modified to dry loads of in-shell peanuts would provide several advantages to peanut producers and peanut processing facility operators. Producers who have HBST for transporting grain would have an additional use for their HBST and would reduce harvest delays during peak harvest times when trailer availability is limited from peanut processors. Additionally, smaller processing facilities would gain the economic advantages of semi-trailers without the investment in hydraulic lifts to unload peanut drying van semi-trailers. Before this study, no HBST had been modified to add peanut drying functionality. The objectives of this study were to design, fabricate, and test the performance of drying modifications to a HBST. After review of the functional components needed to dry peanuts and existing structural constrains of the HBST, the components fabricated were an air inlet connection, an enclosed transition space, an air plenum vent, and air exhaust vents on the undersides of the hopper tubs. The number, size, and location of the air exhaust vents were determined using a computational fluid dynamic model. Three test loads of peanuts were dried in the modified HBST during the 2020 peanut harvest season. Measurements were taken at intervals throughout the peanut drying process to assess drying and to monitor air temperature and relative humidity. Results of a test load indicated that the moisture content decreased from 12.9% wet basis (w.b.) to 12.0% w.b. after 8.5 h of drying. Average moisture content was reduced to 11.1% w.b. following an additional 8.6 h without the dryer operating. The sample load official grade moisture content was 9.1% w.b after the rest period. The most important finding was that a moisture gradient persisted in the loads of peanuts after active drying and rest period. The peanuts located at the top of the load had a moisture content of 9% w.b. while those with the highest moisture content of 14% w.b. were at the bottom of the load. The official inspection sampling procedure did not detect the moisture content differences in the test loads. The finding of a persistent moisture gradient will require more investigation and modification of the HBST. Keywords: Computational Fluid Dynamics, CFD, Design, Drying, Hopper-bottom semi-trailer, Moisture distribution, Moisture gradient, Peanuts, Retrofit.

Objective To describe pain intensity and interference in people with progressive multiple sclerosis (MS), compare these with people with relapsing-remitting multiple sclerosis (RRMS), and identify common and unique factors associated with pain intensity in people with progressive MS and RRMS. Design Observational, cross-sectional analysis using baseline data from a longitudinal survey on quality of life in participants with MS. Setting Community. Participants A total of 573 adults with MS (N=573; progressive MS, n=142; RRMS, n=431). Interventions Not applicable. Main Outcome Measures Average pain intensity was measured by an 11-point numeric rating scale, and pain interference was measured by the Patient-Reported Outcomes Measurement Information System Pain Interference Short Form. Results Participants with progressive MS reported moderate average pain intensity (3.22±2.50) and elevated pain interference (T score of 55.55±9.13). They did not differ significantly from those with RRMS in average pain intensity or pain interference. Common factors associated with higher average pain intensity were more severe disability, lower education level, unemployment, and current smoking. In those with progressive MS, older age was associated with lower average pain intensity. Conclusions Pain intensity and interference are similar across MS types. In addition to assessing and treating pain, it is important to screen for modifiable pain-related factors, such as smoking cessation, in this population.

To examine the relationship between neuropsychological functioning and performance-based functional capacity in veterans with a history of mild traumatic brain injury (mTBI), as well as the moderating effects of age and psychiatric symptoms on this relationship.Three Veterans Affairs medical centers.One hundred nineteen Iraq/Afghanistan veterans with a history of mTBI and self-reported cognitive difficulties.Cross-sectional, secondary data analysis of baseline measures in a randomized controlled trial.The main outcome measure, functional capacity, was assessed using the objective and performance-based University of California San Diego Performance-based Skills Assessment-Brief. A global deficit score (GDS) was created as a composite score for performance on a battery of neuropsychological measures assessing domains of attention, processing speed, executive functioning, and verbal memory performance. Posttraumatic stress disorder (PTSD) symptom severity was assessed using the PTSD Checklist-Military Version, and depressive symptom severity was assessed using the Beck Depression Inventory, Second Edition.Bivariate analyses indicated that worse neuropsychological performance (ie, higher GDS) and greater PTSD symptom severity were associated with worse communication abilities and worse overall functional capacity. Multiple linear regressions demonstrated that GDS and PTSD symptom severity explained 9% of the variance in communication and 10% of the variance in overall functional capacity; however, GDS emerged as the only significant predictor in both regressions. Age, PTSD, and depressive symptom severity did not moderate the relationship between GDS and overall functional capacity. Performance in the verbal learning and memory domain emerged as the strongest neuropsychological predictor of communication and overall functional capacity.Worse neuropsychological functioning was moderately associated with worse performance-based functional capacity, even when accounting for PTSD symptom severity. Verbal learning and memory was the primary neuropsychological domain driving the relationship with functional capacity; improvement in verbal learning and memory may translate into improved functional capacity.

Background and purpose Many persons with multiple sclerosis (PwMS) experience cognitive impairments, which may affect their ability to engage in physical therapy. There is limited information on how cognitive impairments are associated with PwMS' ability to participate and improve their functional outcomes. This study aimed to assess the relationship between cognitive functioning and PwMS' attendance, total goal attainment, and functional improvement following physical therapy intervention. Methods Participants (n = 45) were PwMS who participated in a larger self-management study and enrolled in physical therapy within the past 2 years. Objective cognitive functioning was examined using tests of prospective memory, retrospective memory, working memory, and processing speed, along with a self-report measure. Bivariate analyses were conducted to examine the relationship between cognitive functioning and each physical therapy outcome (session attendance, attaining goals, and changes in functional outcome measures), followed by logistic regressions with age, education, gender, and disability level as covariates. Results Difficulty learning new verbal information was associated with a greater likelihood of "no showing" one or more of their physical therapy sessions. Reductions in working memory and processing speed were associated with PwMS not meeting all their rehabilitation goals. Despite deficits in new learning, memory, and processing speed, 85.2% of those with pre-/postscores showed improvements in at least one functional outcome measure following physical therapy intervention. Discussion and conclusions These findings demonstrate the ability for PwMS to make functional motor gains despite the presence of cognitive impairments and highlight the potential contributions of cognitive functioning on attendance and goal attainment of physical therapy intervention.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A362, which includes background, methods, results, and discussion in the authors' own voices).

Fatigue is one of the most common and disabling symptoms of multiple sclerosis (MS). A recent randomized controlled trial comparing a fatigue self-management program and a general MS education program found that both programs improved fatigue in participants with MS. Participants were randomized to a self-management program (Fatigue: Take Control, n = 109) or an MS education program (MS: Take Control, n = 109). This secondary analysis of that trial used multilevel moderation analysis to examine moderators of treatment-related effects on fatigue (Modified Fatigue Impact Scale) from baseline through the 6-month follow-up. The following potential treatment moderators were examined: age, sex, cohabitation/marital status, and baseline levels of self-efficacy, depression symptoms, and sleep quality. Cohabitation status (living with or without a spouse/partner) interacted with intervention group and time to predict fatigue impact (p = .04). Fatigue: Take Control participants who lived with a spouse/partner showed a marginal effect in greater rate of improvement in fatigue compared to those who lived alone (p = .08). However, rates of improvement in fatigue in MS: Take Control participants were similar in those living with or without a spouse/partner. These findings suggest that living with a spouse or partner may facilitate benefit from self-management interventions for MS-related fatigue. Future research should investigate the contribution of supportive others in self-management of fatigue in MS.

Objective To (1) evaluate the effects of a group-based self-management treatment intervention (VETPALS) on physical and psychosocial functioning (primary outcomes) and quality of life (secondary outcome) in individuals with amputation and (2) examine the feasibility and acceptability of the intervention in a large national health care system. Design Randomized controlled trial with masked outcome assessment. Setting Five Veterans Affairs medical centers geographically dispersed across the United States. Participants 147 individuals with amputation during the past 2 years due to chronic limb threatening ischemia (N=147). Interventions Participants were randomized into VETPALS (N =71) or education control (N=76). VETPALS consisted of a 4-hour workshop and 4 additional 2-hour sessions addressing self-management skills, health and activity, managing emotions, communication and social support, and maintaining goals and gains. Education control consisted of the provision of amputation-related educational materials and provider follow-up if requested. Main Outcome Measures Primary outcomes were physical functioning (Short Musculoskeletal Functional Assessment) and psychosocial functioning (Patient Health Questionnaire-9). Secondary outcomes were quality of life (global) and quality of life (satisfaction with health) from the World Health Organization Quality of Life Scale (brief). Assessment was conducted at baseline, 6 weeks (treatment completion), and 6 months (follow-up). Results Participants randomized to VETPALS reported significantly improved psychosocial functioning and quality of life (satisfaction with health) relative to controls at 6 months (B=1.84; 95% confidence interval, 0.37,3.31 and B=−0.61; 95% confidence interval, −1.11,-0.12, respectively). There were no differences in physical functioning over time between VETPALS and education control at either time point. Follow-up multiple imputation sensitivity analyses produced an identical pattern of results. Among VETPALS participants, treatment initiation was low (56%), but treatment retention (93% attended 4 of 5 classes) and overall satisfaction (100% reported very helpful or better and would recommend to a friend) were high. Conclusions Group-based self-management improves psychosocial functioning for individuals with amputation due to chronic limb threatening ischemia. In-person participation is challenging for this population, but individuals who successfully initiate treatment typically persist and are highly satisfied.

While personality traits have been well-documented to be related to resilience in several populations, they have yet to be explored in people with multiple sclerosis (PwMS). As such, this study aimed to understand how personality traits are associated with MS-related resilience after considering the independent contributions of self-efficacy, a significant component of the biopsychosocial model of resilience in MS, and demographic and disease characteristics.Participants (Self-efficacy (This study highlights how neuroticism, along with self-efficacy and marital status, plays a role in MS-related resilience. While further research is needed, these findings may help inform future resilience-building interventions or identify individuals at greater risk for lower levels of resilience. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

BACKGROUND The Multiple Sclerosis Resiliency Scale (MSRS) was designed to assess factors connected to resilience when facing MS-related challenges. Although the MSRS has demonstrated good internal consistency and construct validity, its test-retest reliability has yet to be established. Identifying the minimal detectable change (MDC) of the scale will also improve its utility as an outcome measure for resilience-based interventions. This study aimed to determine the test-retest reliability and MDC of the MSRS. METHODS Participants were 62 persons with MS who completed the MSRS twice, with a mean ± SD of 16.60 ± 3.97 days (range, 14–30 days) between assessments. Test-retest reliability was evaluated using a 2-way, random-effects, single-measurement intraclass correlation coefficient (ICC), with agreement between time 1 and time 2 visualized with a Bland-Altman plot. The MDC was calculated using the standard error of measurement with a 95% CI. RESULTS At time 1, the mean ± SD MSRS score was 77.19 ± 11.97 (range, 45.83–97.00); at time 2, the mean ± SD score was 76.38 ± 12.75 (range, 46–98). The MSRS total score had good test-retest reliability (ICC = 0.88), with the subscale ICCs ranging from 0.77 (MS Peer Support) to 0.93 (Spirituality). The MDC for the total score was 11.95. CONCLUSIONS These findings suggest that the MSRS has good test-retest reliability and that persons with MS with a difference of 12 points or more between assessments have experienced a reliable change. The results support the utility of the MSRS as a potential outcome measure for MS-related resilience.

Background Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding “shared territory” among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries. Purpose To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes. Methods Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP. Results Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores. Conclusions Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.

The objective of the study was to examine the BIS-BAS model of chronic pain. This model posits that 2 neurophysiological systems-the behavioral inhibition system (BIS) sensitized to and activated by punishment cues and the behavioral activation system (BAS) sensitized to and activated by reward cues-make independent and concurrent contributions to 2 domains of pain-related function: pain interference and positive function despite pain. The study additionally hypothesized that BIS and BAS sensitivity would have different associations with these 2 different aspects of pain-related function. BIS activation would be more strongly correlated with pain interference and BAS would be more strongly correlated with positive function despite pain. Research Method/Design: This was a cohort study consisting of the baseline assessments of 328 veterans enrolled in a large clinical trial examining 3 psychosocial interventions for chronic pain.In multivariable regression adjusting for demographic factors and pain intensity, BIS was associated with greater pain interference and less positive function despite pain. BAS was associated with greater positive function despite pain but to a lesser degree than BIS.As hypothesized, BIS and BAS both contributed to pain-related function; however, BIS displayed stronger associations with both pain interference and positive function despite pain. Thus, the hypothesis that BIS-BAS relationships would differ based on the nature of the functional outcome (BIS resulting in poorer function because of pain and BAS better function despite pain) was only partially supported. Findings of the current study suggest the role of BIS in chronic pain may be more pervasive across functional outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Highlights Changes in yield, losses, and quality due to delayed harvest were evaluated. No significant changes in potential yield were observed over three years. Observed yield decreased late season with lodging present. Losses at the combine head represented largest fraction of measured loss. Abstract . Potential changes in yield and harvest losses that can occur while field drying corn are key considerations when evaluating harvest timing and energy costs associated with artificial drying. This study presents a three-year evaluation of corn harvest in Kentucky. Potential yield, observed yield, measured losses, and quality changes were monitored in a single field at multiple points over the harvest season to assess changes with respect to time and moisture. Measured losses were typically less than 1% of the potential yield in a good standing crop, consistent with results from cooperator combines (0.8% to 2.4%). When lodging was present, variability increased, and measured losses increased to between 5.3% and 9.1% of the potential yield, primarily as a result of ears missed by the combine head. No significant changes in potential yield were found, indicating potential yield was stable over the period examined. In two of the three seasons evaluated, extended delays resulted in an increase in lodging, and the observed yield was significantly reduced by up to 42.5%. Allowing the grain to field dry generally improved test weight; however, there was a trend of increased mold and other damage with prolonged field drying in one season. Keywords: Combines, Grain quality, Harvest loss, Maize, Preharvest loss.

Background Depression, fatigue, and pain commonly co-occur in multiple sclerosis (MS) and are positively associated with one another. However, it is unclear whether treatment-related improvement in one of these symptoms is associated with improvements in the other two symptoms. Purpose This study examined whether early improvements in depressive symptoms, fatigue impact, and pain interference during a multisymptom intervention in persons with MS were associated with overall improvements in the other two symptoms. Methods Secondary analysis of a randomized controlled trial in which both treatments improved depressive symptoms, fatigue, and pain interference. Adults with MS experiencing chronic pain, chronic fatigue, and/or moderate depressive symptoms (N = 154, 86% women) participated in an 8-week, telephone-delivered intervention: self-management (n = 69) or education (n = 85); intervention groups were combined for the current study. Outcome measures were depressive symptoms (PHQ-9), fatigue impact (Modified Fatigue Impact Scale), and pain interference (Brief Pain Inventory). Path analysis examined associations between pre-to-mid intervention improvement in one symptom (i.e., depression, fatigue, pain interference) and pre-to-post (overall) improvement in the other two symptoms. Results Early reduction in depressive symptoms was associated with an overall reduction in pain interference and fatigue impact (p’s < .01). Early reduction in fatigue impact was associated with an overall reduction in depressive symptom severity (p = .04) but not pain interference. Early reduction in pain interference was not associated with reductions in fatigue impact or depressive symptoms. Conclusions These findings suggest the potential importance of reducing depressive symptoms to overall improvement in fatigue and pain interference in persons with MS. Clinical Trial Registrations NCT00944190.

Individuals undergoing amputations typically present with comorbid conditions that may adversely impact mortality, mobility, residual limb healing, mood, function, and participation. Understanding how to manage these individuals holistically is essential to optimize function and reduce complications. A review of recent literature suggests that a biopsychosocial, interprofessional approach remains the recommended approach to limb loss rehabilitation. This can include the following: (1) optimizing health behaviors and fostering self-management skills; (2) assessing cognitive functioning and training use of assistive technology and compensatory strategies to facilitate learning and activities of daily living specific to limb loss (e.g., prosthetic use, novel self-care routines); (3) using empirically supported treatments for mood disorders to enhance motivation and participation in rehabilitation; and (4) managing pain and pain interference by fostering realistic expectations, teaching skills (e.g., cognitive-behavioral and mindfulness meditation), and enhancing behavioral activation. An interprofessional rehabilitation team employing a biopsychosocial approach can reduce mortality and improve quality of life, mobility, health, function, mood, and participation.

OBJECTIVE The purpose of this study was to determine modifiable predictors of intervention adherence in a study of group-based Compensatory Cognitive Training (CCT) for Iraq/Afghanistan War veterans with a history of mild traumatic brain injury (mTBI). METHODS One hundred twenty-three veterans enrolled in a randomized controlled trial of a 10-week CCT intervention (54 assigned to CCT) and were evaluated at baseline, 5 weeks, 10 weeks, and 15 weeks. CCT adherence was determined by the number of CCT sessions attended, with more sessions indicative of greater adherence. Baseline demographic and clinical characteristics, and subjective and objective neuropsychological performance, were examined in relation to CCT session attendance. RESULTS Older age and worse attention performance at baseline were associated with higher CCT attendance rates. CONCLUSIONS This study generates preliminary evidence for potential modifiable neuropsychological factors that may improve engagement in CCT interventions.

Objective To determine which factors are associated with suboptimal disease-modifying therapy (DMT) adherence and to develop an explanatory model that could be used to identify individuals at risk and potentially inform interventions. Design Cross-sectional cohort study using electronic health records. Setting Veterans Health Administration (VA). Participants Veterans with multiple sclerosis (MS) (N=2939; 79.69% men) who received care through the VA and were included in the VA MS Center of Excellence Data Repository. Interventions Not applicable. Main Outcome Measures Suboptimal DMT adherence ( Results Nearly 31% of participants had suboptimal adherence. Flags for suboptimal adherence included >20% missed appointments (odds ratio [OR], 3.78; 95% CI, 2.45-2.82), traumatic brain injuries (OR, 1.55; 95% CI, 1.12-2.14), age younger than 59 years (OR, 1.47; 95% CI, 1.23-1.74), ≥1 emergency department visits (OR, 1.40; 95% CI, 1.18-1.67), mood disorders (ie, depressive and bipolar disorders) (OR, 1.40; 95% CI, 1.18-1.66), and service connection (OR, 1.22; 95% CI, 1.01-1.47). Hyperlipidemia (OR, 0.77; 95% CI, 0.65-0.92) and being issued a wheelchair (OR, 0.83; 95% CI, 0.70-1.00) were associated with lower risk. Conclusions Suboptimal adherence to DMTs continues to be an issue. Interventions that focus on person-level barriers should be urgently explored to increase adherence and improve self-management abilities.

Objective: Aging with physical disability disrupts one’s ability to achieve valued goals due to changes in symptoms and function. It is unclear how to cope optimally in this context. This study examined whether two possible strategies—tenacious goal pursuit (TGP) and flexible goal adjustment (FGA)—were associated with reduced pain interference and depressive symptoms and greater well-being, and protected against pain intensity, and FGA was more protective with increasing age and worse physical function. Method: Middle-aged adults with muscular dystrophy, multiple sclerosis, post-polio syndrome, or spinal cord injury ( N = 874; MAGE = 58.3 years, range = 46-68; MDISEASEDURATION = 26.2 years, range = 2-67) completed two questionnaires, a year apart. Results: TGP and FGA use was associated with greater well-being. FGA use predicted decreased depressive symptoms. Concurrent use of both predicted decreased pain interference. Discussion: Adults with disability employ a variety of goal management strategies. Findings support TGP and FGA as potential intervention targets for healthy aging with disabilities.

While comorbidities have been associated with all-cause hospitalizations among persons with multiple sclerosis (MS), there has been no examination of their role in all-cause emergency department (ED) utilization. As such, this study aimed to determine if the presence of comorbidities increases the odds of ED usage in a national sample of Veterans with MS.Data were extracted retrospectively from the Veterans Affairs (VA) MS Center of Excellence Data Repository, an electronic health record-based dataset. Veterans who had at least one outpatient visit in 2013, were alive in 2015, and were initially prescribed a disease modifying therapy were included in the dataset (n = 3,742). Current Procedural Terminology codes were used to determine if participants had at least one ED visit during a 24-month time frame beginning 1/1/2013. Comorbidities were identified using ICD-9 codes present before 2013. Separate logistic regressions were conducted for the overall number of comorbidities and categorized comorbidities, adjusting for age, race, and sex.Nearly 32% (n = 1,191) had at least one ED visit, with those Veterans having an average of 6.67 (SD=3.32) comorbidities. After adjusting for demographics, the number of comorbidities was a significant predictor of ED usage (aOR=1.20; 95% CI: 1.17, 1.23, p.001). Several comorbidities emerged as independent contributors.All-cause ED utilization is prevalent in MS, with usage increasing in the presence of other chronic conditions. These findings underscore the need to view long-term MS care through the lens of chronic disease management.

Fatigue is one of the most common and disabling symptoms of multiple sclerosis. A recent randomized controlled trial comparing a fatigue self-management program and a general multiple sclerosis education program found that both programs improved fatigue in participants with multiple sclerosis. Participants were randomized to a self-management program (fatigue: take control, n = 109) or a multiple sclerosis education program (multiple sclerosis: take control, n = 109). This secondary analysis of that trial used multilevel moderation analysis to examine moderators of treatment-related effects on fatigue (Modified Fatigue Impact Scale) from baseline through the 6-mo follow-up. The following potential treatment moderators were examined: age, sex, cohabitation/marital status, and baseline levels of self-efficacy, depression symptoms, and sleep quality. Cohabitation status (living with or without a spouse/partner) interacted with intervention group and time to predict fatigue impact (P = 0.04). Fatigue: take control participants who lived with a spouse/partner showed a marginal effect in greater rate of improvement in fatigue compared with those who lived alone (P = 0.08). However, rates of improvement in fatigue in multiple sclerosis: take control participants were similar in those living with or without a spouse/partner. These findings suggest that living with a spouse or partner may facilitate benefit from self-management interventions for multiple sclerosis-related fatigue. Future research should investigate the contribution of supportive others in self-management of fatigue in multiple sclerosis.

Purpose There is limited qualitative research on the experience of patients undergoing lower limb amputation due to chronic limb threatening ischemia (CLTI) and their participation in amputation-level decisions. This study was performed to understand patient lived experiences related to amputation and patient involvement in shared decision making. Materials and methods Phenomenological interviews were conducted with Veterans 6–12 months post transtibial or transmetatarsal amputation due to CLTI. Interviews were read and summarized by two analysts who discussed the contents of each interview and relationships between interviews to identify emergent, cross-cutting elements of patient experience. Results Twelve patients were interviewed between March and August 2019. Three cross cutting elements of patient lived experience and participation in shared decision making were identified: 1) Lacking a sense of decision making; 2) Actively working towards recovery as response to a perceived loss of independence; and 3) Experiencing amputation as a Veteran. Conclusions Patients did not report a high level of involvement in shared decision making about their amputation or amputation level. Understanding patient experiences and priorities is crucial to supporting shared decision making for Veterans with amputation due to CLTI.

Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.

Background Women Veterans with amputation are a group with unique needs whose numbers have grown over the last 5 years, accounting for nearly 3% of all Veterans with amputation in 2019. Although identified as a national priority by the Veterans Health Administration, the needs of this population have remained largely underrepresented in amputation research. Objective To describe the experiences of women Veterans with lower extremity amputation (LEA) related to prosthetic care provision and devices. Design National qualitative study using semi-structured individual interviews. Participants Thirty women Veterans with LEA who had been prescribed a prosthesis at least 12 months prior. Approach Inductive content analysis. Key Results Four key themes emerged: (1) a sense of “feeling invisible” and lacking a connection with other women Veterans with amputation; (2) the desire for prosthetic devices that meet their biological and social needs; (3) the need for individualized assessment and a prosthetic limb prescription process that is tailored to women Veterans; the current process was often perceived as biased and either dismissive of women’s concerns or failing to adequately solicit them; and (4) the desire for prosthetists who listen to and understand women’s needs. Conclusions Women Veterans with LEA articulated themes reminiscent of those previously reported by male Veterans with LEA, such as the importance of prostheses and the central role of the provider-patient relationship. However, they also articulated unique needs that could translate into specific strategies to improve prosthetic care, such as integrating formal opportunities for social support and peer interaction for women Veterans with LEA, advocating for administrative changes and research efforts to expand available prosthetic component options, and ensuring that clinical interactions are gender-sensitive and free of bias.

Monitoring the temperature of stored grain with permanent cables suspended from the bin roof is common practice in commercial grain storage and is sometimes used in on-farm grain storage bins. Knowledge of the forces imparted on the cables by flowing grain is required for proper design of cables, connection hardware, and bin roofs, but there is little data in the literature for full size bins. To determine forces on different cable sizes and configurations, five different cable designs were tested during filling and emptying of wheat and corn. Two concrete storage bins, 4.6-m diameter and 25-m maximum depth, were used with cables suspended from the center of the bin or suspended 0.6 m from the sidewall. The bottom ends of the cables were weighted, but were not fully restrained. Forces on the cables were monitored during filling and emptying of the bins. Forces during emptying usually exhibited slip-stick behavior. The greatest forces were during emptying, where forces were often double those during filling, with vertical forces up to 4.7 kN for the largest cable. Both peak and average forces for bin emptying were significantly larger than corresponding forces for bin filling. Results showed no effect of grain type (corn or wheat) while cable size had significant effects on peak and average force in most cases. Keywords: Corn, Design load, Force, Grain bin, Temperature monitoring cable, Wheat.

OBJECTIVES (1) To identify the rate of short-notice canceled appointments in a large national sample of persons with multiple sclerosis (MS) and (2) examine the demographic and clinical factors associated with frequent cancellations. DESIGN Retrospective cross-sectional cohort using electronic health records. SETTING Veterans Health Administration. PARTICIPANTS Veterans with MS (N=3742) who were part of the Veterans Health Administraiton's MS Center of Excellence Data Repository and (1) had at least one outpatient appointment at the VA in 2013, (2) were alive in 2015, and (3) were prescribed a disease modifying therapy (DMT). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Frequent short-notice cancellations, defined as >20% of scheduled appointments canceled with less than 24-hour notification over a 24-month period. This threshold was based on the definition of ≤80% for suboptimal treatment adherence. Several demographics and clinical variables were examined as potential explanatory factors. RESULTS Approximately 75% (n=2827) had at least 1 short-notice cancellation, with more than 3% (n=117) categorized as frequent cancelers. The odds of frequent cancellations were greater in women (odds ratio [OR], 1.81; P=.004) and among 18- to 44-year-olds (OR, 2.77; P=.004) and 45- to 64-year-olds (OR, 2.49; P=.003) compared to those over 65. The odds were lower among persons who lived

The bulk density with current baling technology is too low to utilise the full transportation capacity. For square bales, bulk density is limited by the pressure generated by the baler, density settings, and the ability of baling twine to withstand the expansion forces shortly after ejection from the bale chamber. This study explores crushing the stem on the pressure required to compact the material and the rebounding forces generated after compression. Uniaxial compression tests were conducted on bulk samples of switchgrass at three moisture levels (nominally 10%, 20%, and 45%) and miscanthus at two moisture levels (nominally 10% and 20%) to evaluate crushing. The pressure required to compress the material to 256 dry kg m−3 and the materials' stress relaxation behaviour were used as evaluation metrics. Crushing the material resulted in a significant decrease in the compression required for both crops. The peak stress was reduced from 577 to 441 kPa (a decrease of 23.6%) and from 581 to 365 kPa (a decrease of 37.2%) for switchgrass and miscanthus, respectively. Moisture level was also significant for both crops at the 10% and 20% moisture level with the low moisture material requiring higher pressures to reach the target densities. The final pressure after 5 min of relaxation was significantly lower for crushed material by 37.6% for miscanthus and 24.2% for switchgrass. However, this result from the reduction in peak stress at the end of the compression cycle, and relaxation behaviour was more affected by moisture level than by processing treatment.

Objective To examine associations among compensatory cognitive training (CCT), objective cognitive functioning, and self-reported cognitive symptoms. We examined whether change in objective cognitive functioning associated with participation in CCT at 10-week follow-up mediates change in self-reported cognitive symptoms associated with CCT at 15-week follow-up. Setting Three VA outpatient mental health clinics. Participants Veterans with a history of mild traumatic brain injury who reported cognitive deficits. Design Randomized controlled trial post hoc causal mediation analysis. Main measures Self-reported cognitive symptoms were measured by the Prospective-Retrospective Memory Questionnaire and the Multiple Sclerosis Neuropsychological Screening Questionnaire. Objective cognitive functioning was measured using a battery of neuropsychological tests. Results Improvement on the Hopkins Verbal Learning Test-Revised (HVLT-R) Delayed Recall test mediated the association between participation in CCT and decrease in the Prospective-Retrospective Memory Questionnaire total score. Improvement on the HVLT-R Total Recall and HVLT-R Delayed Recall tests both meditated the association between participation in CCT and decrease in the Multiple Sclerosis Neuropsychological Screening Questionnaire total score. No other measures of objective cognitive functioning were significant mediators. Conclusion Patients' perceptions of cognitive symptom improvement due to CCT are partially mediated by learning and memory, though these subjective improvements occur regardless of other changes in objective cognitive functioning associated with CCT.

Objective Psychological treatments for chronic low back pain (CLBP) are effective. However, limited research has investigated their neurophysiological mechanisms. This study examined electroencephalography- (EEG-) assessed brain oscillation changes as potential mechanisms of cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for CLBP. The a priori bandwidths of interest were changes in theta, alpha and beta power, measured at pre- and post-treatment. Design A secondary analysis of a clinical trial. Setting University of Queensland Psychology Clinic. Subjects Adults (N = 57) with CLBP who completed pre- and post-treatment EEG and pain outcome assessments. Methods EEG data were examined for five regions of interest (ROIs); the primary outcome was pain intensity. Results A significant reduction in theta (P=.015) and alpha (P=.006) power in the left frontal ROI across all treatments was found, although change in theta and alpha power in this region was not differentially associated with outcome across treatments. There were significant reductions in beta power in all five ROIs across all treatments (P≤.013). Beta power reduction in the central ROI showed a significant association with reduced pain intensity in MBCT only (P=.028). Changes in other regions were not statistically significant. Conclusions These findings provide support for the capacity of psychological CLBP treatments to induce changes in brain activity. The reduced beta power in all five ROIs indicated that all three treatments engendered a state of lowered cortical arousal. The growing body of research in this area could potentially inform novel directions towards remedying central nervous system abnormalities associated with CLBP.

Objectives Persons with multiple sclerosis (MS) can face a number of potential healthcare-related barriers, for which mobile health (mHealth) technology can be potentially beneficial. This review aimed to understand the frequency, current uses, and potential barriers with mHealth usage among persons with MS. Methods A query string was used to identify articles on PubMed, MEDLINE, CINAHL, and IEEE Xplore that were published in English between January 2010 and December 2019. Abstracts were reviewed and selected based on a priori inclusion and exclusion criteria. Fifty-nine peer-reviewed research studies related to the study questions are summarized. Results The majority of persons with MS were reported as using smartphones, although rates of mHealth utilization varied widely. mHealth usage was grouped into 3 broad categories: (1) disability and symptom measurement; (2) interventions and symptom management; and (3) tracking and promoting adherence. While there have been an increasing number of mHealth options, certain limitations associated with MS (eg, poor dexterity, memory problems) may affect usage, although including persons with MS in the design process can address some of these issues. Discussion Given the increased attention to mHealth in this population and the current need for telehealth and at home devices, it is important that persons with MS and healthcare providers are involved in the development of new mHealth tools to ensure that the end product meets their needs. Considerations for addressing the potential mHealth use barriers in persons with MS are discussed.

Providing a satisfactory, functional prosthesis following lower-limb amputation is a primary goal of rehabilitation. The objectives of this study were to describe the rate of successful prosthetic fitting over a 12 mo period; describe prosthetic use after amputation; and determine factors associated with greater prosthetic fitting, function, and satisfaction. The study design was a multicenter prospective cohort study of individuals undergoing their first major lower-limb amputation because of vascular disease and/or diabetes. At 4 mo, unsuccessful prosthetic fitting was significantly associated with depression, prior arterial reconstruction, diabetes, and pain in the residual limb. At 12 mo, 92% of all subjects were fit with a prosthetic limb and individuals with transfemoral amputation were significantly less likely to have a prosthesis fit. Age older than 55 yr, diagnosis of a major depressive episode, and history of renal dialysis were associated with fewer hours of prosthetic walking. Subjects who were older, had experienced a major depressive episode, and/or were diagnosed with chronic obstructive pulmonary disease had greater functional restriction. Thus, while most individuals achieve successful prosthetic fitting by 1 yr following a first major nontraumatic lower-limb amputation, a number of medical variables and psychosocial factors are associated with prosthetic fitting, utilization, and function.

Objectives To (1) describe depressive symptom severity and suicidal ideation (SI) in persons with progressive multiple sclerosis (MS); (2) compare depressive symptom severity and SI in persons with progressive MS and persons with relapsing-remitting multiple sclerosis (RRMS); and (3) identify common and unique risk factors for greater depressive symptom severity and SI in persons with progressive MS compared with individuals with RRMS. Design Observational, cross-sectional survey study. Setting Community. Participants Adults with MS (N=573). Interventions Not applicable. Main Outcome Measures The dependent variables were depression symptoms and any SI measured by the Patient Health Questionnaire-9. Comparisons between groups used t tests and chi-square analyses, and risk factors were tested by examining the interaction of MS subtype (progressive MS and RRMS) and each risk factor in multiple regression models with bootstrapping. Results Persons with progressive MS did not differ from persons with RRMS in levels of depressive symptoms or SI. Both groups reported mild depressive symptoms and approximately 10% endorsed SI. Common risk factors for greater depressive symptom severity were younger age, greater disability, greater speech and swallowing problems, and lower household income. Common risk factors for SI were shorter disease duration, greater disability, and greater speech and swallowing problems. Conclusions In this sample, there were no group differences between persons with progressive MS and persons with RRMS in depressive symptom severity and SI. Although both groups reported mild depressive symptoms on average, nearly 1 in 4 persons met criteria for probable major depression, which underscores the importance of screening for and treating depressive disorders in all persons with MS.

OBJECTIVE Chronic pain rehabilitation warrants sensitivity to unique psychosocial factors, such as trauma history. In Veterans of the United States Armed Forces, military sexual trauma (MST) is a pervasive type of trauma associated with a host of physical and psychological sequelae. A growing literature suggests a relationship between history of MST and chronic pain. This study sought to clarify the relationship between MST and chronic pain among male and female Veterans and explore whether individual factors moderate this relationship. DESIGN A baseline survey of 328 Veterans seeking care for chronic pain via behavioral pain treatments was conducted. RESULTS MST was reported by 31.4% of the sample and uniquely predicted pain interference. A significant interaction was found between MST and age, such that younger Veterans with a history of MST reported greater pain interference than younger Veterans with no MST. CONCLUSION Findings provide further evidence that the experience of MST may intensify the overall burden of chronic pain and suggest that younger Veterans with MST seem to be most vulnerable to impaired pain rehabilitation. Unique study contributions include a robust sample of women and men with elevated rates of MST and examination of MST-age relationships concurrent with chronic pain.

IMPORTANCE: Multiple sclerosis (MS) is a complex and unpredictable neurologic disease affecting nearly 1 million people in the US. People with MS commonly experience multiple physical and psychological symptoms such as depression, anxiety, stress, fatigue, and pain that impact functioning and quality of life. Subsequently, living with MS requires routine management of MS symptoms, adaptation to challenges, and engagement in health behaviors to promote well-being over time. OBSERVATIONS: There is considerable evidence that behavioral interventions that increase cognitive and/or behavioral skills to address the challenges of day-to-day life with MS can promote resilience and reduce overall distress associated with this chronic and unpredictable disease. Brief group-based cognitive-behavioral therapy (CBT) and CBT-based interventions (eg, self-management) have been shown to reduce symptoms of depression, anxiety, stress, fatigue, and pain in people with MS, including via telehealth delivery. Likewise, mindfulness-based interventions have been shown to improve depression, anxiety, stress, fatigue, and quality of life in people with MS. Behavioral interventions also have been shown to improve health behaviors such as physical activity and adherence to disease modifying therapies in MS. Unlike other treatment options, behavioral interventions can be delivered in various formats (eg, in-person, telehealth), are time-limited, and cause few (if any) undesirable systemic side effects. CONCLUSIONS: Behavioral intervention is an integral component of interprofessional care and key aspect of living well with MS.

Objective To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS. Design Secondary analysis of a single-blind randomized controlled trial. Setting Community. Participants Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States. Interventions Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88). Main Outcome Measures Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation). Results Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes. Conclusions At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.

Objective To examine the extent to which pain catastrophizing, fatigue catastrophizing, positive affect, and negative affect simultaneously mediated the associations between common symptoms of multiple sclerosis (MS; i.e., pain, fatigue) and impact on daily life, depressive symptoms, and resilience. Method Participants were community-dwelling adults with MS (N = 163) reporting chronic pain, fatigue, and/or moderate depressive symptoms. Multiple mediation path analysis was used to model potential mediators of pain and fatigue separately, using baseline data from a randomized controlled trial comparing two symptom self-management interventions. Results In the pain model, pain catastrophizing was a mediator of pain intensity with pain interference and depression. Negative affect was a mediator of pain intensity with depression and resilience. In the fatigue model, fatigue catastrophizing was a mediator of fatigue intensity with fatigue impact and depression. Positive affect was a mediator of fatigue intensity with depression and resilience. Conclusions These findings provide preliminary support for the presence of differential effects of cognitive-affective mediators and suggest potential targets for psychological interventions based on an individual's clinical presentation. The differential mediating effects also support the inclusion of both positive and negative aspects of psychological health in models of pain and fatigue, which would not be otherwise apparent if negative constructs were examined in isolation. To our knowledge, this is the first study to utilize a multivariate path analysis approach to examine cognitive-affective mediators of pain and fatigue in MS, while also examining positive and negative constructs concurrently. (PsycINFO Database Record