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MR imaging is a noninvasive imaging modality that is commonly used during clinical follow up and has been widely utilized to reconstruct realistic 3D vascular models for patient-specific analysis. In a recent work, we utilized patient-specific hemodynamic analysis of the circle of Willis to noninvasively assess stroke risk in pediatric Moyamoya disease (MMD)—a progressive steno-occlusive cerebrovascular disease that leads to recurrent stroke. The objective was to identify vascular regions with critically high wall shear rate (WSR), signifying elevated stroke risk. However, sources of error including insufficient resolution of MR images can negatively impact vascular model accuracy, especially in areas of severe pathological narrowing, and thus diminish clinical relevance of simulation results, as local hemodynamics are sensitive to vessel geometry. We have developed a novel method to improve the accuracy of MR-derived 3D vascular models utilizing 2D X-ray angiography (XA), which is considered the gold standard for clinically assessing vessel caliber. In this workflow, “virtual angiographies” (VA) of 3D MR-derived vascular models are conducted, producing 2D projections that are compared to corresponding XA images guiding the local adjustment of modeled vessels. This VA-comparison-adjustment loop is iterated until the two agree, as confirmed by an expert neuroradiologist. Using this method, we generated models of the circle of Willis of two patients with a history of unilateral stroke. Blood flow simulations were performed using a Navier-Stokes solver within an isogeoemtric analysis framework and WSR distributions were quantified. Results for one patient show as much as 45% underestimation of local WSR in the stenotic left anterior cerebral artery (LACA) and up to a 60% underestimation in the right anterior cerebral artery when using the initial MR-derived model compared to the XA-adjusted model, emphasizing the need for verifying improved accuracy of the adjusted model. To that end, vessel cross-sectional areas of the pre- and post-adjustment models were compared to those seen in 3D CTA images of the same patient. CTA has superior resolution and signal to noise ratio compared to MR imaging but is not commonly used in clinic due to radiation exposure concerns, especially in pediatric patients. While the vessels in the initial model had normalized root mean squared deviations (NRMSDs) ranging from 26% to 182% and 31% to 69% in two patients with respect to CTA, the adjusted vessel NRMSDs were comparatively smaller (32% to 53% and 11% to 42%). In the mildly stenotic LACA of patient 1, the NRMSDs for the pre- and post-adjusted models were 49% and 32%, respectively. These findings suggest that our XA-based adjustment method can considerably improve the accuracy of vascular models, and thus, stroke-risk prediction. An accurate individualized assessment of stroke risk would be of substantial clinical benefit because it would help guide the timing of preventative surgical interventions in pediatric MMD patients.

More than 100 millisecond pulsars (MSPs) have been discovered in radio observations of gamma-ray sources detected by the Fermi Large Area Telescope (LAT), but hundreds of pulsar-like sources remain unidentified. Here we present the first results from the targeted survey of Fermi-LAT sources being performed by the Transients and Pulsars with MeerKAT (TRAPUM) Large Survey Project. We observed 79 sources identified as possible gamma-ray pulsar candidates by a Random Forest classification of unassociated sources from the 4FGL catalogue. Each source was observed for 10 minutes on two separate epochs using MeerKAT's L-band receiver (856-1712 MHz), with typical pulsed flux density sensitivities of $\sim$100$\,\mu$Jy. Nine new MSPs were discovered, eight of which are in binary systems, including two eclipsing redbacks and one system, PSR J1526$-$2744, that appears to have a white dwarf companion in an unusually compact 5 hr orbit. We obtained phase-connected timing solutions for two of these MSPs, enabling the detection of gamma-ray pulsations in the Fermi-LAT data. A follow-up search for continuous gravitational waves from PSR J1526$-$2744 in Advanced LIGO data using the resulting Fermi-LAT timing ephemeris yielded no detection, but sets an upper limit on the neutron star ellipticity of $2.45\times10^{-8}$. We also detected X-ray emission from the redback PSR J1803$-$6707 in data from the first eROSITA all-sky survey, likely due to emission from an intra-binary shock., Comment: 17 pages, 8 figures, accepted for publication in MNRAS

To characterize transient and prolonged body position patterns in a large sample of nursing home (NH) residents and describe the variability in movement patterns based on time of occurrence.This study is a descriptive, exploratory analysis of up to 28 days of longitudinal accelerometer data for 1,100 NH residents from the TEAM-UP (Turn Everyone and Move for Ulcer Prevention) clinical trial. Investigators analyzed rates of transient events (TEs; less than 60 seconds) and prolonged events (PEs; 60 seconds or longer) and their interrelationships by nursing shift.Residents' positions changed for at least 1 minute (PEs) nearly three times per hour. Shorter-duration movements (TEs) occurred almost eight times per hour. Residents' PE rates were highest in shift 2 (3 pm to 11 pm ), when the median duration and maximum lengths of PEs were lowest; the least active time of day was shift 3 (11 pm to 7 am ). Three-quarters of all PEs lasted less than 15 minutes. The rate of TEs within PEs decreased significantly as the duration of PEs increased.The NH residents demonstrate complex patterns of movements of both short and prolonged duration while lying and sitting. Findings represent how NH residents naturally move in real-world conditions and provide a new set of metrics to study tissue offloading and its role in pressure injury prevention.

BACKGROUND An assessment tool is needed to measure clinical severity of nursing home residents to improve prediction of outcomes and provide guidance in treatment planning. OBJECTIVE To describe development of a Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. METHODS A retrospective, non-experimental design was used to develop and validate a Nursing Home Severity Index using secondary data from nine nursing homes participating in the 12-month pre-intervention period of the TEAM-UP pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury was accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident’s Worst-Braden score with/without severity dimensions generated propensity scores. Goodness-of-fit for overall models was assessed using C statistics; significance of improvement of fit after adding severity components to the model was determined using the Likelihood Ratio Chi Square test. Significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm reliability of the severity measure. Finally, discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. RESULTS Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C-statistics measuring predictive accuracy increased 19.3% (from 0.627 to 0.748, P CONCLUSIONS A clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This Index has the potential to significantly impact quality of care decisions aimed at improving individual pressure injury prevention plans. CLINICALTRIAL ClinicalTrials.gov NCT123456.

Nursing staff assessment to accurately identify pressure injury (PrI) risk is a hallmark in PrI prevention care. Risk scores from the Braden Scale for Predicting Pressure Sore Risk© (hereafter Braden), a commonly used tool for assessing PrI risk, signal the need for preventative care. Braden Mobility, Activity, and Sensory Perception subscale subgroups associated with repositioning movement features help identify preventative strategies that minimize pressure intensity and duration. Evidence confirming subscale rating accuracy is needed. This study compared assessment score accuracy with movement data collected via accelerometer sensor. Sample included 913 nursing home residents from the Turn Everyone and Move for Pressure Ulcer Prevention (TEAM-UP) cluster randomized trial. Movements and Braden Mobility and Activity subscale scores were evaluated for significant differences and associations. Mobility subgroups explained a small-medium amount of variance in mean lying and upright movement features (0.002 ≤ R2 ≤ 0.195). Activity subgroups explained a small-medium amount of variance in mean lying, upright, and ambulating movements (0.016 ≤ R2 ≤ 0.248). Significant associations occurred among subscale subgroups and most movements. Nursing assessment ratings using Braden scale’s Mobility and Activity subscale scores are accurate indicators of actual repositioning movements and can be relied upon for PrI prevention care planning for older adults.

Objective To evaluate the effect of providing quasi-contextualized speech therapy, defined as metacognitive, compensatory, or strategy training applied to cognitive and language impairments to facilitate the performance of future real-life activities, on functional outcomes up to 1 year following traumatic brain injury (TBI). Setting Acute inpatient rehabilitation. Participants Patients enrolled during the TBI-Practice-Based Evidence (TBI-PBE) study (n = 1760), aged 14 years or older, who sustained a severe, moderate, or complicated mild TBI, received speech therapy in acute inpatient rehabilitation at one of 9 US sites, and consented to follow-up 3 and 9 months postdischarge from inpatient rehabilitation. Design Propensity score methods applied to a database consisting of multisite, prospective, longitudinal observational data. Main measures Participation Assessment with Recombined Tools-Objective-17, FIM Motor and Cognitive scores, Satisfaction With Life Scale, and Patient Health Questionnaire-9. Results When at least 5% of therapy time employed quasi-contextualized treatment, participants reported better community participation during the year following discharge. Quasi-contextualized treatment was also associated with better motor and cognitive function at discharge and during the year after discharge. The benefit, however, may be dependent upon a balance of rehabilitation time that relied on contextualized treatment. Conclusions The use of quasi-contextualized treatment may improve outcomes. Care should be taken, however, to not provide quasi-contextualized treatment at the expense of contextualized treatment.

Obesity (body mass index [BMI] ≥30 kg/m2) can have a profound influence on the likelihood of developing a pressure injury (PrI); little is known about the movement behaviors (movement frequency, body position frequency, and position duration) of obese individuals. Purpose This report examines 2 cases of obese nursing home residents and their movement behaviors in relation to their potential influence on overall PrI risk. Methods Resident movements were monitored 24 hours/day using a wearable sensor, and repositioning events were observed as part of a larger study examining repositioning intervals. Braden Pressure Ulcer Risk Assessment was conducted weekly. Results Both residents (BMI 39 kg/m2 and 50 kg/m2) had limitations in movement with prolonged periods spent in a single body position. Each resident addressed movement challenges unique to their desire to remain mobile and level of dependency on nursing staff. Conclusion Presence of obesity is a factor affecting resident movement and creates environmental and psychosocial barriers to health. Nurses can play a key role in PrI prevention by addressing these barriers and encouraging positive, long-term behavior changes that mitigate risk. Future research should guide tailored PrI prevention protocols and national/ international guidelines for obese residents.

Objective: To develop a venous leg ulcer (VLU) risk stratification system for use in research and clinical practice. Approach: U.S. Wound Registry data were examined retrospectively and assigned an outcome. Bivariate analysis identified significant variables (p

Registries are a powerful tool for clinical research. Clinical registries for cerebral palsy can aid in comparative effectiveness research, especially using the practice-based evidence model. The Cerebral Palsy Research Network (CPRN) was initiated in 2014 as a patient-centered, multidisciplinary registry. The leadership group initiated a 4-stage participatory action research process: listen, reflect, plan/analyze, and take action. CPRN also joined with CP NOW, an advocacy group, to create a research agenda for cerebral palsy. With more than 20 centers and growing, CPRN hopes to generate evidence for developing best practices and measure their implementation and impact for individuals with cerebral palsy throughout North America.

Academy IRISThis retrospective analysis included eyes implanted with 1 of 2 IOL brands, with ≥365 days of follow-up available in the IRIS Registry, and ≥2 visits within 180 days of surgery. Analyses included Nd:YAG incidence due to PCO within 1 year after surgery by IOL type and brand, mean time to PCO diagnosis, and mean time to Nd:YAG.Of 89,947 eyes after cataract surgery, 24,834 (28%) had PCO diagnosis within 365 days, and 9262 (10%) underwent Nd:YAG; 4.1% of 57,523 eyes with monofocal and 21.2% of 32,424 eyes with diffractive multifocal (MF) or diffractive extended depth of focus (EDOF) IOLs had Nd:YAG. Nd:YAG was 3.2 times more likely in eyes with diffractive MF or diffractive EDOF IOLs versus monofocal. For monofocal IOLs, 3.2% of eyes with AcrySofReal-world data for AcrySof and Tecnis IOLs revealed lower Nd:YAG rates and longer time to PCO diagnosis and Nd:YAG after monofocal versus diffractive multifocal or diffractive EDOF implantation. Nd:YAG rates were significantly lower with AcrySof versus Tecnis IOLs.

To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks.An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity.From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P.001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P.001).Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened.

Background An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning. Objective This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. Methods A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident’s Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. Results Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index–Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P Conclusions The clinical Nursing Home Severity Index–Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans. Trial Registration ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331

Moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular disease leading to recurrent stroke. There is a lack of reliable biomarkers to identify unilateral stroke MMD patients who are likely to progress to bilateral disease and experience subsequent contralateral stroke(s). We hypothesized that local hemodynamics are predictive of future stroke and set out to noninvasively assess this stroke risk in pediatric MMD patients. MR and X-ray angiography imaging were utilized to reconstruct patient-specific models of the circle of Willis of six pediatric MMD patients who had previous strokes, along with a control subject. Blood flow simulations were performed by using a Navier–Stokes solver within an isogeometric analysis framework. Vascular regions with a wall shear rate (WSR) above the coagulation limit (>5,000 s−1) were identified to have a higher probability of thrombus formation, potentially leading to ischemic stroke(s). Two metrics, namely, “critical WSR coverage” and “WSR score,” were derived to assess contralateral stroke risk and compared with clinical follow-up data. In two patients that suffered a contralateral stroke within 2 months of the primary stroke, critical WSR coverages exceeding 50% of vessel surface and WSR scores greater than 6× the control were present in multiple contralateral vessels. These metrics were not as clearly indicative of stroke in two additional patients with 3–5 year gaps between primary and contralateral strokes. However, a longitudinal study of one of these two cases, where a subsequent timepoint was analyzed, suggested disease stabilization on the primary stroke side and an elevated contralateral stroke risk, which was confirmed by patient outcome data. This indicates that post-stroke follow-up at regular intervals might be warranted for secondary stroke prevention. The findings of this study suggest that WSR-based metrics could be predictive of future stroke risk after an initial stroke in pediatric MMD patients. In addition, better predictions may be possible by performing patient-specific hemodynamic analysis at multiple timepoints during patient follow-up to monitor changes in the WSR-based metrics.

Background and PurposeMoyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular disease leading to recurrent stroke. There is a lack of reliable biomarkers to identify unilateral stroke MMD patients who are likely to progress to bilateral disease and experience subsequent contralateral stroke(s). We hypothesized that local hemodynamics are predictive of future stroke and set out to noninvasively assess this stroke risk in pediatric MMD patients.MethodsMR and X-ray angiography imaging were utilized to reconstruct patient-specific models of the circle of Willis of 6 pediatric MMD patients who had previous strokes, along with a control subject. Blood flow simulations were performed by using a Navier-Stokes solver within an isogeometric analysis framework. Vascular regions with a wall shear rate (WSR) above the coagulation limit (> 5000 s−1) were identified to have a higher probability of thrombus formation, potentially leading to ischemic stroke(s). Two metrics, namely, “critical WSR coverage” and “WSR score”, were derived to assess contralateral stroke risk and compared with clinical follow-up data.ResultsIn two patients that suffered a contralateral stroke within two months of the primary stroke, critical WSR coverages exceeding 50% of vessel surface and WSR scores greater than 6x the control were present in multiple contralateral vessels. These metrics were not as conclusive in two additional patients with 3-to-5-year gaps between primary and contralateral strokes. However, a longitudinal study of one of these two cases, where a subsequent timepoint was analyzed, accurately predicted disease stabilization on the primary stroke side and an elevated contralateral stroke risk, thus indicating that post-stroke follow-up at regular intervals might be warranted for secondary stroke prevention.ConclusionsWSR-based metrics could be predictive of future stroke risk after an initial stroke in MMD patients. In addition, more accurate predictions may be possible by performing patient-specific hemodynamic analysis at multiple timepoints during patient follow-up to monitor changes in the WSR-based metrics.

Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD ( n = 62, 70%) and non-ADRD ( n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.

The current study aimed to investigate the long-term effects of receiving post-amputation physical therapy (PT) on individuals' self-reported functional outcomes and quality of life in middle-aged to older adults with lower limb amputation (LLA). Further, we qualitatively explored the patients' perception and experience of PT post-amputation. We assessed participants' functional outcomes using Short-Form Health Survey, Prosthetic Evaluation Questionnaire-Physical Mobility portion, and Fear of Falling Avoidance Behavior Questionnaire. Furthermore, participants' experience and perception to PT were assessed through in-person interviews guided by the custom Amputation Patient Perception Survey. Functional outcome scores were compared between participants who have (Yes-PT) and have not (No-PT) received PT following their amputations, controlling for age. Perception to PT was qualitatively analyzed. Out of the 70 participants, 56 had received PT (80%) following amputation. Functional outcome scores were not significantly different between Yes-PT and No-PT groups. Among participants in the Yes-PT group, 84% expressed overall positive perception toward their post-amputation PT care. Main positive and negative perceptions were related to outcome/benefits and unfulfilled needs/lack of benefits, respectively. Participants with LLA generally expressed a positive perception of PT. However, no significant long-term benefits were found. We recommend goal-directed intervention with patient engagement to improve care experience.

Background: Pressure injuries (PrIs) cause pain and infection, lengthen institutional care, raise healthcare costs, and hasten death in nursing home (NH) residents. Repositioning residents to offload pressure on tissues is the most common prevention strategy, yetthe optimal interval remains uncertain.Objective: Investigate clinical effectiveness of three nursing-home-wide repositioning intervals (2-,3-, or 4-hours) without compromising PrI incidence in four weeks in adult nursing home residents.Design, Setting, and Participants: Anembedded pragmatic cluster randomized controlled trial was conducted in 9 NHs from a large proprietary system located in 34 states. Each NH was randomly assigned to one of three NH-wide repositioning interval Arms (every 2, 3, or 4 hours). Data were provided for 12-month Baseline and 4-week Intervention during the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) study. Intervention residents were without current PrIs, had PrIrisk (Braden Score) ≥10 (low, mild, moderate, or high risk; not severe risk), and used viable 7” high-density foam mattresses.Methods: Each Arm included three NHs with assigned single repositioning interval as standard care during the 4-week Intervention. Mandatory staff education sessions were provided.A wireless patient monitoring system, using wearable single-use patient sensors, cued staff by displaying resident repositioning need on conveniently placed monitors.Primary outcome was PrI incidence; secondary outcome was staff repositioning compliance fidelity.Results: Eleven hundred residents from 9 NHs were fitted with sensors; 108 of these were ineligible for some analyses due to missing Baseline data. Effective sample size included 992 residents (mean age 78 years [SD13]; 63% female). Pressure injury incidence during the Intervention was 0.0% compared to 5.24% in Baseline, even though Intervention resident clinical risk scores were significantlyhigher (pConclusions: This study contributes to understanding alternativerepositioning intervalssuggestingcurrent 2-hour protocolscan be relaxed for many without compromising PrI development. Causal link was not established between three repositioning interval treatments and primary outcome—PrIs; however, no new PrIs developed. Cueing staff may benefit repositioningimplementation; compliance improved as repositioning interval lengthened.Trial Registration: (ClinicalTrials.gov Identifier: NCT02996331).Date: 16/05/2017

Extracellular vesicles (EVs) are small, membrane-bound vesicles released by cells as a means of intercellular communication. EVs transfer proteins, nucleic acids, and other biologically relevant molecules from one cell to another. In the context of viral infections, EVs can also contain viruses, viral proteins, and viral nucleic acids. While there is some evidence that the inclusion of viral components within EVs may be part of the host defense, much of the research in this field supports a pro-viral role for EVs. Packaging of viruses within EVs has repeatedly been shown to protect viruses from antibody neutralization while also allowing for their integration into cells otherwise impervious to the virus. EVs also bidirectionally cross the blood-brain barrier (BBB), providing a potential route for peripheral viruses to enter the brain while exiting EVs may serve as valuable biomarkers of neurological disease burden. Within the brain, EVs can alter glial activity, increase neuroinflammation, and induce neurotoxicity. The purpose of this mini-review is to summarize research related to viral manipulation of EV-mediated intercellular communication and how such manipulation may lead to infection of the central nervous system, chronic neuroinflammation, and neurodegeneration.

Objective To evaluate the effect of family attendance at inpatient rehabilitation therapy sessions on traumatic brain injury (TBI) patient outcomes at discharge and up to 9 months postdischarge. Design Propensity score methods are applied to the TBI Practice-Based Evidence database, a database consisting of multisite, prospective, longitudinal, and observational data. Setting Nine inpatient rehabilitation centers in the United States. Participants Patients (N=1835) admitted for first inpatient rehabilitation after an index TBI. Intervention Family attendance during therapy sessions. Main Outcome Measures Participation Assessment for Recombined Tools-Objective-17 (Total scores and subdomain scores of Productivity, Out and About, and Social Relations), Functional Independence Measure, Satisfaction with Life Scale, and Patient Health Questionnaire-9. Results Participants whose families were in attendance for at least 10% of the treatment time were more out and about in their communities at 3 and 9 months postdischarge than participants whose families attended treatment less than 10% of the time. Although findings varied by propensity score method, improved functional independence in the cognitive area at 9 months was also associated with increased family attendance. Conclusions Family involvement during inpatient rehabilitation may improve community participation and cognitive functioning up to 9 months after discharge. Rehabilitation teams should engage patients' families in the rehabilitation process to maximize outcomes.

Objective Given evidence that malnutrition and immobility increase the risk of pressure injuries (PIs) in nursing home (NH) residents and that body mass index guidelines related to undernutrition may differ between Asian and non-Asian populations, the purpose of this study was to describe differences in overall nutrition, dietary intake, and nonnutrition risk factors for PIs between Asian and non-Asian NH residents. Design and setting Secondary data analysis of a 3-week PI prevention randomized controlled trial in seven Canadian NHs. Patients Asian (n = 97) and non-Asian (n = 408) residents at moderate or high mobility-related risk of PI. Main outcome measure Incident PI by racial subgroups. Main results Asian residents (PI = 6) consumed significantly smaller meals and marginally different patterns of daily dietary consumption of protein types, liquid supplements, and snacks; took more frequent tub baths; and had marginally lower body mass index than non-Asian residents (PI = 4). Conclusions Findings are consistent with earlier research suggesting that nutrition consumption and care patterns may predispose Asian NH residents to develop more PIs than their non-Asian counterparts. Future research should focus on the threshold for and types of nutrition support sufficient to improve nutrition status and reduce PI risk.

Background Low body mass index (BMI) is suspected of being associated with low transdermal fentanyl (TDF) blood levels and worse pain relief. Clinical pain data to support this claim are lacking. Methods Using a Chronic Pain Registry, we identified 901 cancer patients who received TDF at outpatient pain service clinics of our cancer center from 7/1/2011 to 12/1/2016. Of these, 240 patients had a BMI measure, pain intensity, and pain relief scores documented within 30 days of a TDF order. We examined associations between BMI, TDF dose, Worst and Least pain scores, and pain relief scores using standard statistical tests. Results In cancer patients receiving TDF, low BMI (, Low body mass index (BMI) is suspected of being associated with low transdermal fentanyl (TDF) blood levels and worse pain relief. Of the 240 patients who reported patient‐reported outcomes, whereas on TDF, patients with lowest BMI trended toward better pain relief on the lowest TDF doses. When predicting percent pain relief, we found no basis for avoiding TDF or modifying its dose in cancer patients with low BMI and cachexia.

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIMTM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

Objectives To describe development and testing of a physical therapy treatment code documentation taxonomy. Design Clinician survey within a practice-based evidence study framework for patients with lymphedema. Setting Outpatient physical therapy clinics within a large public health care service using a central electronic medical record. Participants Certified lymphedema therapists (CLTs) (N=43). Intervention Treatment coding of 10 treatment vignettes representing real-life clinical scenarios. The CLTs were asked to accurately select 35 activity-intervention combination codes. Main Outcome Measures The CLT score represented percentage of treatment codes accurately selected by each therapist. The code score represented percentage of CLTs who accurately selected each treatment code. Results The mean CLT score was 91%, with 72% of CLTs meeting the 90% criterion. Personal feedback was provided to each CLT. The mean code score was also 91%; with 71% of treatment codes meeting the 90% criterion. We identified 9 low-score codes needing additional education or found to be redundant. These codes were either clarified or removed. Conclusions The proposed treatment code documentation system for lymphedema therapy was found to be clear and accurately used by most CLTs. Specific needs for improvement were identified. Follow-up testing is warranted to ensure ongoing accurate implementation of the treatment documentation system.

Objectives To explore the patterns of cognitive and motor recovery at 4 time points from admission to 9 months after discharge from inpatient rehabilitation (IR) and to investigate the association of therapeutic factors and conditions before and after discharge with long-term outcomes. Design Secondary analysis of traumatic brain injury (TBI) and practice-based evidence dataset. Setting IR in Ontario, Canada. Participants Patients with TBI consecutively admitted for IR between 2008 and 2011 who had data available from admission to 9 months after discharge (N=85). Interventions Not applicable. Main Outcome Measure FIM-Rasch cognitive and motor scores at admission, discharge, 3 months after discharge, and 9 months after discharge. Results Cognitive and motor recovery showed similar patterns of improvement with recovery up to 3 months but no significant change from 3 to 9 months. Having fewer postdischarge health conditions was associated with better long-term cognitive scores (95% confidence interval, -13.06 to -1.2) and added 9.9% to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% confidence interval, .02 to .09) and fewer postdischarge health conditions (95% confidence interval, -19.5 to -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively. Conclusion Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR.

SUMMARY The effects of phytase superdosing on digestibility and bone development of broilers from 1 to 21 d of age were evaluated. Ninety-six male broilers of the Cobb Slow lineage were housed in metaboilic cages, distributed in a completely randomized design with 4 treatments and 8 replicates. The treatments were positive control without phytase, negative control with phytase (500 FTU), negative control with phytase (1000 FTU), and negative control with phytase (2000 FTU). From 16 to 21 d of age, total excreta samples were collected for digestibility analyses. To evaluate bone quality at 21 d of age, 2 broilers per experimental unit were slaughtered and the femur and tibia were collected. Data were analyzed by regression test. A quadratic effect of phytase inclusion for the diameter and percentage of Ca and P of the femur was observed, in which the inclusion of 1,494 and 1,220 FTU, respectively, showed the best results. For the evaluation of the tibia, the diameter, length and weight linearly increased with the inclusion of phytase, and for resistance a quadratic effect was observed, in which 1265 FTU was the best inclusion. Regarding digestibility, a quadratic effect for EEDC (Ether extract digestibility coefficient), MMDC (mineral matter digestibility coefficient), AME (Apparent metabolizable energy), and AMEn (Nitrogen-corrected apparent metabolizable energy) was observed, in which the inclusion of 1,734; 788; 1,204; and 1,255 FTU resulted in the highest values, respectively. Phytase superdosing improved bone development and broiler digestibility at 21 d.

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (

Concerns regarding anatomical anomalies and worsening neurological symptoms have prevented widespread use of epidural catheters in patients with low level spina bifida. We hypothesize that thoracic epidural placement in the T9 to T10 interspace is safe and decreases narcotic requirements following major open lower urinary tract reconstruction in patients with low level spina bifida.We reviewed consecutive patients with low level spina bifida who underwent lower urinary tract reconstruction and received epidurals for postoperative pain control. Controls were patients with low level spina bifida who received single injection transversus abdominis plane blocks and underwent similar procedures. Complications of epidural placement, including changes in motor and sensory status, were recorded. Opioid consumption was calculated using equivalent intravenous morphine doses. Mean and maximum pain scores on postoperative days 0 to 3 were calculated.Ten patients with low level spina bifida who underwent lower urinary tract reconstruction with epidural were matched to 10 controls with low level spina bifida who underwent lower urinary tract reconstruction with transverse abdominis plane block. Groups were demographically similar. All patients had full abdominal sensation and functional levels at or below L3. No epidural complications or changes in neurological status were noted. The epidural group had decreased opioid consumption on postoperative days 0 to 3 (0.75 mg/kg vs 1.29 mg/kg, p = 0.04). Pain scores were similar or improved in the epidural group.Thoracic epidural analgesia appears to be a safe and effective opioid sparing option to assist with postoperative pain management following lower urinary tract reconstruction in individuals with low level spina bifida.

SIGNIFICANCE After a dilated eye examination, many patients experience symptoms of prolonged light sensitivity, blurred vision, and cycloplegia associated with pharmacological mydriasis. Phentolamine mesylate ophthalmic solution (PMOS) may expedite the reversal of mydriasis in patients, potentially facilitating return to functional vision and reducing barriers to obtaining dilated eye examinations. PURPOSE The protracted reversal time after pharmacologically induced pupil dilation impairs vision. We tested the hypothesis that PMOS rapidly reduces pupil diameter in this acute indication. METHODS In this double-masked placebo-controlled, randomized, two-arm crossover phase 2b trial, we evaluated the effects of one drop of 1% PMOS applied bilaterally in subjects who had their pupils dilated by one of two common mydriatic agents: 2.5% phenylephrine or 1% tropicamide. End points included change in pupil diameter, percent of subjects returning to baseline pupil diameter, and accommodative function at multiple time points. RESULTS Thirty-one subjects completed the study (15 dilated with phenylephrine and 16 with tropicamide). Change in pupil diameter from baseline at 2 hours after maximal dilation with 1% PMOS was -1.69 mm and was significantly greater in magnitude compared with placebo for every time point beyond 30 minutes (P < .05). At 2 hours, a greater percentage of study eyes given 1% PMOS returned to baseline pupil diameter compared with placebo (29 vs. 13%, P = .03), which was this also seen at 4 hours (P < .001). More subjects treated with PMOS in the tropicamide subgroup had at least one eye returning to baseline accommodative amplitude at 2 hours (63 vs. 38%, P = .01). There were no severe adverse events, with only mild to moderate conjunctival hyperemia that resolved in most patients by 6 hours. CONCLUSIONS Phentolamine mesylate ophthalmic solution at 1% reversed medically induced pupil dilation more rapidly than placebo treatment regardless of which mydriatic was used (adrenergic agonists and cholinergic blockers) with a tolerable safety profile.

Assessment of pain, an aversive sensory and emotional experience, is more challenging in children with self-reports and objective pain measures. Subjective nature of pain, the maturity of the child, parental presence and influence, and inability to relate to pain as an experience complicate pediatric pain assessment and eventual treatment. The commonly used age-appropriate subjective and objective pain assessment tools are discussed in this chapter. Multiple treatment modalities including regional analgesia, opioids, non-opioid analgesics, analgesic adjuncts, use of intravenous ketamine and lidocaine, and evidence-based multimodal analgesia in relieving pain and enhancing recovery after surgery are discussed in this chapter.

Magnetic state of exchanged biased CoO(20nm)/Co($d_F$) bilayer ($d_F$=5-20nm) was studied by means of polarized neutron reflectometry. By spacing of CoO/Co bilayer and Al$_2$O$_3$ substrate with Nb(20nm) layer we created waveguide structure which allowed us to significantly enhance intensity of spin-flip (SF) scattering in the position of optical resonances. For the trained sample with thinnest Co(5nm) we detected strong SF scattering at the resonance position (up to 30\% of incoming intensity) speaking about high non-collinearity of the system. As $d_F$ increases, the intensity of SF scattering linearly decreases. At the same time we observed asymmetry of up-down and down-up scattering channels at the resonance positions. We attribute this asymmetry to the Zeeman splitting of neutrons energies with different initial polarization taking place in high external field. Analysis, however, shows that the applied in the PNR experiment external field is not enough to quantitatively explain the observed asymmetry for the samples with $d_F > $ 5nm and we have to postulate presence of additional magnetic field produced by sample. We attribute this additional field to the stray field produced by chiral Bloch domain walls. The chirality of the domain walls can be explained by Dzyaloshinskii-Moriya interaction arising at the CoO/Co interface. Our results can be useful for designing of spintronic devices using exchange bias effect.

Objective The aim of the study was to compare the relative predictive value of Marshall Classification System and Rotterdam scores on long-term rehabilitation outcomes. This study hypothesized that Rotterdam would outperform Marshall Classification System. Design The study used an observational cohort design with a consecutive sample of 88 participants (25 females, mean age = 42.0 [SD = 21.3]) with moderate to severe traumatic brain injury who were admitted to trauma service with subsequent transfer to the rehabilitation unit between February 2009 and July 2011 and who had clearly readable computed tomography scans. Twenty-three participants did not return for the 9-mo postdischarge follow-up. Day-of-injury computed tomography images were scored using both Marshall Classification System and Rotterdam criteria by two independent raters, blind to outcomes. Functional outcomes were measured by length of stay in rehabilitation and the cognitive and motor subscales of the Functional Independence Measure at rehabilitation discharge and 9-mo postdischarge follow-up. Results Neither Marshall Classification System nor Rotterdam scales as a whole significantly predicted Functional Independence Measure motor or cognitive outcomes at discharge or 9-mo follow-up. Both scales, however, predicted length of stay in rehabilitation. Specific Marshall scores (3 and 6) and Rotterdam scores (5 and 6) significantly predicted subacute outcomes such as Functional Independence Measure cognitive at discharge from rehabilitation and length of stay. Conclusions Marshall Classification System and Rotterdam scales may have limited utility in predicting long-term functional outcome, but specific Marshall and Rotterdam scores, primarily linked to increased severity and intracranial pressure, may predict subacute outcomes.

Dementia contributes to the development of pressure injuries (PrIs).This study describes the real-time body positions of 2 nursing home (NH) residents, residing in the United States and living with dementia, to inform development of PrI prevention strategies tailored to individual risk profiles.As part of a larger study, eligible residents were fitted with a triaxial accelerometer sensor placed on the anterior chest to monitor body positions 24-hours daily through a 4-week monitoring period. The current study used an observational, prospective design during routine repositioning events for 2 residents. A convenience sample of 2 residents from a single NH wing who were considered moderately at risk for PrI development (Braden Scale score 13-14) with a Brief Interview for Mental Status score in the severely impaired range were selected based on nursing staff recommendation.Sensor data showed that both residents, although "chairfast" according to the Braden Scale, spent5% in an upright position and the great majority of time reclining at an angle50%. One (1) resident demonstrated a persistent side preference.Wearable sensors are not a long-term solution for protecting those with dementia from PrI formation but do provide a crude picture of overall body positions throughout the 24-hour day that may inform individualized PrI prevention strategies. Studies including large samples of NH residents living with dementia are warranted.

Background Boys with dystrophinopathies (DMD) are at increased risk of low bone mineral density and fracture. Femoral fracture is the most common extremity fracture and is accompanied by significant risk of functional loss. Care considerations for DMD have stressed that aggressive management may be needed to maintain ambulation and that surgical fixation allows early mobilization. Objectives Describe 5 cases of femoral fracture in ambulatory boys with DMD and the course of care undertaken to optimize function. Patients Five boys with DMD median age 15y (12-16) who were independently ambulatory. Median 10m walk speed prior to their first fracture was 8 sec (7-17.37) and 4 of 5 were less than the 9 seconds predictive of 2 year ambulation retention. Three of the cases had a single incident causing fracture; the remaining cases had 2 and 3 incidents respectively representing a total of 8 fractures 6 of which were surgically stabilized. Results Following the first fracture, all 5 subjects regained some form of ambulation. Three patients regained independent ambulation and 2 with hand held support or contact guard. Two subjects went on to have additional falls with associated fracture. No patient regained the ability to rise from the floor and only one of the 5 regained the ability to climb steps and all demonstrated a decline in walking speed. Conclusion Prompt orthopedic intervention, early mobility, and intensive rehabilitation even in the end stage ambulatory patient, were factors in helping preserve function in these patients with dystrophinopathies.

Obesity (body mass index [BMI] ≥30 kg/m2) can have a profound influence on the likelihood of developing a pressure injury (PrI); little is known about the movement behaviors (movement frequency, body position frequency, and position duration) of obese individuals.This report examines 2 cases of obese nursing home residents and their movement behaviors in relation to their potential influence on overall PrI risk.Resident movements were monitored 24 hours/day using a wearable sensor, and repositioning events were observed as part of a larger study examining repositioning intervals. Braden Pressure Ulcer Risk Assessment was conducted weekly.Both residents (BMI 39 kg/m2 and 50 kg/m2) had limitations in movement with prolonged periods spent in a single body position. Each resident addressed movement challenges unique to their desire to remain mobile and level of dependency on nursing staff.Presence of obesity is a factor affecting resident movement and creates environmental and psychosocial barriers to health. Nurses can play a key role in PrI prevention by addressing these barriers and encouraging positive, long-term behavior changes that mitigate risk. Future research should guide tailored PrI prevention protocols and national/ international guidelines for obese residents.

UNSTRUCTURED The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.

There is an unsettled debate on the benefits of mechanical disturbance for native species in fire-prone habitats. We compared the demographic effects of fire and mechanical treatments (Gyro-tracing) on Polygonella myriophylla, a prostrate clonal shrub listed as endangered and narrowly endemic to pyrogenic scrub ecosystems in south-central Florida. This species is commonly found in gaps within a matrix dominated by resprouting shrubs, but also occurs under other shrubs and along the shoulders of adjacent road-side habitats. We designed and executed a replicated (that plots per treatment, 1 ha per plot; total 147 initial plants) experiment including plots burned, mechanically chopped, with both treatments and without treatments at the Lake Wales Ridge Wildlife and Environmental Area - Carter Creek in Highlands County, central Florida (2005-2008; treated in summer of 2005). Cumulative mortality of standing P. myriophylla after 3 y was higher in burned plots (> 80%) than in chopped-only and untreated plots (∼ 50 % and ∼ 40 % respectively). Post disturbance growth in canopy area among the surviving plants was consistently higher in mechanically disturbed plots compared to untreated plots and intermediate burned conditions. We found three putative seedlings, accounting for less than 3% of the initial genets, before treatment application, but many seedlings after treatments. Seedling recruitment (∼ 90) post-treatment was higher in disturbed plots, highest when both treatments occurred together, and almost null in untreated plots. Recruitment was highest in the first-year post disturbance (70%), decreasing in subsequent years. Disturbances may improve the persistence of P. myriophylla by increasing recruitment and individual growth, however; fire and mechanical disturbance should be used with caution for this species given many plants died during treatment.

There is a remarkable phenomenon occurring among health professionals: the development of ongoing, routine collaboration, both in educating the next generation of providers and in delivering care. These new approaches, commonly referred to as interprofessional education and interprofessional collaborative practice, have been introduced into academic health settings and delivery systems throughout the U.S. and the rest of the world; however, the full integration of dentistry in health care teams remains unrealized. In academic settings, dentistry has found ways to collaborate with the other health professions, but most practicing dentists still find themselves on the margins of new models of care delivery. This article provides a perspective on the history and context of the evolution of collaborative approaches to health care and proposes ways in which dentistry can participate more fully in the future.

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management. Perspective This report describes the results of the analyses of PROs and patient-related electronic health record data collected under standard of care from cancer patients at outpatient pain management clinics of Anesthesiology and Palliative Care at the Memorial Sloan Kettering Cancer Center. Consideration of sex and age as predictors of opioid use is critical in attempting to understand PROs and their relationship to pain management.

Pressure ulcers/injuries (PrUs), a critical concern for nursing homes (NH), are responsible for chronic wounds, amputations, septic infections, and premature deaths. PrUs occur most commonly in older adults and NH residence is a risk factor for their development, with at least one of every nine U.S. NH residents experiencing a PrU and many NHs having high incidence and prevalence rates, in some instances well over 20%. PrU direct treatment costs are greater than prevention costs, making prevention-focused protocols critical. Current PrU prevention protocols recommend repositioning residents at moderate, high, and severe risk every 2 h. The advent of visco-elastic (VE) high-density foam support-surfaces over the past decade may now make it possible to extend the repositioning interval to every 3 or 4 h without increasing PrU development. The TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study aims to determine: 1) whether repositioning interval can be extended for NH residents without compromising PrU incidence and 2) how changes in medical severity interact with changes in risk level and repositioning schedule to predict PrU development. In this proposed cluster randomized study, 9 NHs will be randomly assigned to one of three repositioning intervals (2, 3, or 4 h) for a 4-week period. Each enrolled site will use a single NH-wide repositioning interval as the standard of care for residents at low, moderate, and high risk of PrU development (N = 951) meeting the following criteria: minimum 3-day stay, without PrUs, no adhesive allergy, and using VE support surfaces (mattresses). An FDA-cleared patient monitoring system that records position/movement of these residents via individual wireless sensors will be used to visually cue staff when residents need repositioning and document compliance with repositioning protocols. This study will advance knowledge about repositioning frequency and clinically assessed PrU risk level in relation to PrU incidence and medical severity. Outcomes of this research will contribute to future guidelines for more precise preventive nursing practices and refinement of PrU prevention guidelines. Clinical Trial Registration: NCT02996331 .