Greater Percent Change Research Articles

To Hear or Not to Hear: Cognitive Load Theory and Learning

ABSTRACT Background: Cognitive load is the amount of information one’s working memory can process at any given time. Key components of cognitive load include germane load, intrinsic load, and extraneous load. Learning is hindered if overload occurs, thus reducing cognitive performance. This study addresses the impact of auditory stimulation on cognitive load through repeated recognition tasks. Methods: Twenty-eight Queen’s University students were recruited and randomly allocated to control and experimental groups who completed the experiment with noise-cancelling headphones and with ambient noise, respectively. The experiment consisted of learning and testing phases. The learning phase involved memorizing a series of words. Subsequently, the testing phase required participants to recall words from the list. Each trial consisted of one learning and one testing phase, with three trials per participant. Cardiovascular measurements were taken prior to the experiment, at the beginning of each phase, and after each trial was completed. Results: Primary outcomes demonstrated that the experimental group experienced greater percent changes in heart rate and rate pressure product, higher perceived mental effort, and greater within-group variation for heart rate compared to controls. Scores decreased as trials progressed. Secondary outcomes showed that the top 33% of participants were less susceptible to changes in heart rate and blood pressure. Overall, four heart rate or blood pressure responders were identified. Conclusions: Exposure to 70 decibels of ambient noise contributes to cognitive load as noted by elevated cardiovascular measure and perceived mental effort. Results can inform educational platforms and hospital logistics.

Lipid changes across menopause status point to increased cardiovascular risk

Abstract Background While women develop cardiovascular disease (CVD) approximately ten years later than men, risk of CVD in women rises precipitously following menopause. The mechanisms underlying this acceleration in CVD risk are not well elucidated, but adverse changes in lipid measures are known to occur during the perimenopause period. Previous investigations have been largely restricted to traditional lipid measures and have not examined changes in lipoprotein particles including lipid subfractions and particle number. Purpose We sought to examine longitudinal changes in lipoprotein particles that occur during the menopause transition. Methods A total of 1305 participants in the Dallas Heart Study with known menopause status underwent measurement of LDL-P, HDL-P, sd-LDL, and ld-HDL by NMR LipoProfile LP4 algorithm (LabCorp, Raleigh Durham, NC, U.S.A.) at 2 examinations (between 7-8 years between DHS studies). We compared longitudinal changes in lipoprotein measures between pre-, peri-, post-menopausal women and men using multivariable adjusted linear regression models. For our analysis peri- is the group that was pre-menopause at DHS I and post-menopause at DHS 2, not to mean the period before menopause. Results There 1346 men (referent group) included in the study with a mean age of 43 ± 9.4 years. There was a total of 1246 women with a mean age of 42 ± 5.6 for peri-group, 54 ± 6.2 for post-group, and 34 ± 3.08 for the pre-group. Of the women 440 (35.3%) were pre-menopausal, 298 (23.9%) were peri-menopausal, and 508 (40.8%) were post-menopausal. Over a median follow-up time of 7 years. All three groups had an increase in LDL-P but the greatest percent change is between peri and post, 18.30 (SE 3.05, P<0.001). When compared to men the post-group has the greatest percent change of HDL-P with a negative change of 4.77 (SE 0.948 P<0.0001). Small-dense LDL had the highest percent change in the peri- group when compared to men with a change of 578.62 (SE 288.45, P<0.045). Large-dense HDL had greatest percent change in the post- group when compared to men with negative change of 37.84 (SE 12.83, P<0.0032). Conclusions We found that menopause is associated with adverse changes in lipoprotein profiles, with the most pronounced changes in LDL-particles and subfractions observed for peri-menopausal women. By contrast, post-menopausal women demonstrated the greatest reductions in HDL-particles and subfractions. Taken together, these changes suggest that menopause is associated with a transition to a more atherogenic lipoprotein profile. Further research is needed to investigate whether these adverse changes in lipoproteins translate to greater CV risk.

Optimizing maintenance therapy in responders to abrocitinib induction: A post hoc analysis of JADE REGIMEN.

Treatment optimization may require dosing flexibility. The Phase 3 JADE REGIMEN trial (NCT03627767) evaluated maintenance of abrocitinib 200 mg-induced response in patients with moderate-to-severe atopic dermatitis (AD) randomly assigned to subsequent maintenance with continuous-dose abrocitinib (200 mg), reduced-dose abrocitinib (100 mg) or placebo. Maintenance with continuous-dose abrocitinib was associated with a stronger prevention of disease flares, but also with a higher occurrence of adverse events, compared with the reduced dose. This post hoc analysis of JADE REGIMEN aimed to identify predictors of not flaring during the maintenance period and to generate tools that can be used to assess probability of not flaring. Data were analysed from patients who responded to abrocitinib 200 mg induction therapy (12 weeks) and were randomly assigned to receive abrocitinib (200 mg or 100 mg) or placebo in the 40-week maintenance period. Demographic and baseline disease characteristics and level of response to induction were evaluated for association with not flaring using logistic regression. Parameters with a significant (p < 0.15) interaction with the treatment arm were fitted into a multivariable regression model, which was used to assess probability of not flaring. Lower percentage body surface area affected at baseline (p = 0.09), absence of prior exposure to systemic agents (p = 0.02) and greater percentage change in EASI from baseline to randomization (p < 0.001) were identified as predictors of not flaring with abrocitinib. In both abrocitinib arms, percentage change in EASI from baseline to end of induction (Week 12) was the major contributor to the probability of not flaring in the maintenance period. Maintenance of response using reduced-dose abrocitinib 100 mg may be feasible for patients with lower baseline disease severity and strong response to abrocitinib 200 mg induction treatment.

Safety and efficacy of tofacitinib in 97 alopecia areata patients.

Alopecia areata (AA) is a recurrent immune-mediated disorder causing hair loss without any scarring being present. It affects hairs on the head or other parts of the body and can occur at any age and in both genders. It seems that AA is associated with a higher rate of psychological disorders resulting from hair loss and the esthetic and social repercussions of it. Common treatments like corticosteroids do not work for every patient and recent treatment options focusing on the immunologic mechanisms like tofacitinib have shown some promising results. It's a retrospective study on patients with AA, AT, AU taking oral tofacitinib as a treatment for at least 6 months. Scalp hair loss was assessed before treatment and at each visit using the Severity of Alopecia Tool (SALT) score. Of 97 cases, 69.1% demonstrated over 50% SALT score improvement, with 44.3% having 90% or more decrease in SALT score. Patients who suffered from patchy AA were more responsive compared to patients with AT and AU subtypes and had a greater percent change in SALT score. Tofacitinib was tolerated quite well and no significant adverse events were reported. Tofacitinib should be taken into consideration as an efficacious treatment option for patients with AA, AT and AU.

Factors Associated with Persistent Efficacy of Abrocitinib without Flare: A Multivariable Analysis of the JADE-REGIMEN Study

Introduction: JADE REGIMEN (NCT03627767) was conducted to evaluate the feasibility of continual, reduced dose or withdrawal of abrocitinib after induction of response in patients with moderate-to-severe atopic dermatitis (AD). This post hoc analysis evaluated patient factors associated with a higher probability of persistent clinical response with abrocitinib, without flare, during a 40-week maintenance period.Methods: Data were analyzed from patients who responded to abrocitinib 200 mg induction therapy (12 weeks) and were randomly assigned to receive abrocitinib (200 or 100 mg) or placebo in the maintenance period (40 weeks). A multivariable logistic regression model with fixed and random effects was fit to determine factors associated with not experiencing flare by week 52. Fixed effects (factors) considered were randomly allocated treatment, age (&lt;18 vs ≥18 years), race, weight, prior use of systemic agents, AD duration, onset of response in induction (early vs late), Investigator’s Global Assessment score at randomization, body surface area (BSA, ≤50% vs &gt;50%) at baseline, and percentage change in Eczema Area and Severity Index (EASI) at randomization. Backward elimination and stepwise model selection procedures were applied with entry and exit criteria based on a P value threshold of 5%.Results:1233 patients received abrocitinib 200 mg in the induction period. By week 12, 798 (64.7%) achieved a response and were randomly assigned to receive maintenance treatment for 40 weeks. In total, 356 patients (44.6%) experienced a protocol-defined flare: 16.5% (200 mg), 39.6% (100 mg), and 77.5% (placebo). After model selection, the analysis identified continuation of treatment with abrocitinib 200 mg (odds ratio [OR], 19.51; 95% CI, 11.28-33.75) or reduced-dose abrocitinib 100 mg (5.27; 3.29-8.46) as the greatest predictors of not experiencing flare during maintenance. Not having previously used systemic agents (OR, 1.53; 95% CI, 1.09-2.14), lower baseline BSA (1.55; 1.10-2.17), and greater percentage reduction of EASI during induction (1.35; 1.15-1.59) were also associated with not experiencing flare.Conclusions: Multivariable analysis of JADE REGIMEN indicated that maintenance treatment with abrocitinib in patients with AD reduced the risk for flare in a dose-dependent manner. Other factors associated with maintaining response to treatment without flare included no previous exposure to systemic agents, lower extent of BSA involvement at baseline, and greater percent change in EASI during induction. These findings may assist clinicians with abrocitinib dosing decisions in the future.

Testosterone therapy reduces insulin resistance in men with adult-onset testosterone deficiency and metabolic syndrome. Results from the Moscow Study, a randomized controlled trial with an open-label phase.

To describe changes in homeostasis model assessment of insulin resistance index (HOMA-IR) following testosterone therapy in men with hypogonadism and metabolic syndrome (MetS). A randomized, placebo-controlled, double-blind randomized controlled trial (RCT) comprising 184 men with MetS and hypogonadism (testosterone undecanoate [TU]: 113 men, placebo: 71 men) was conducted. This was followed by an open-label phase in which all men were given TU. We focused on men who were not receiving antiglycaemic agents (TU: 81 men; placebo: 54 men) as these could affect HOMA-IR. Inter-group comparison of HOMA-IR was restricted to the RCT (30 weeks), whilst intra-group comparison was carried out on men provided TU during the RCT and open-label phases (study cohort) and men given placebo during the RCT and then switched to TU during the open-label phase (confirmatory cohort). Regression analysis was performed to identify factors associated with change in HOMA-IR (∆HOMA-IR). The median HOMA-IR was significantly reduced at almost every time point (after 18 weeks) compared to baseline in men receiving TU in both the study and confirmatory cohorts. There was a significant decrease in median values of fasting glucose (30 weeks: -2.1%; 138 weeks: -4.9%) and insulin (30 weeks: -10.5%; 138 weeks: -35.5%) after TU treatment. Placebo was not associated with significant ∆HOMA-IR. The only consistent predictor of HOMA-IR decrease following TU treatment was baseline HOMA-IR (r2 ≥ 0.64). Baseline HOMA-IR predicted ΔHOMA-IR, with a greater percentage change in insulin than in fasting glucose. In men with MetS/type 2 diabetes (T2DM) not on antiglycaemic therapy, improvements in HOMA-IR may be greater than suggested by change in fasting glucose. Our results suggest that hypogonadism screening be included in the management of men with MetS/T2DM.

Changes in physical function in older women with endometrial cancer with or without adjuvant therapy.

To evaluate changes in physical function (PF) for older women with endometrial cancer (EC) + / - adjuvant therapy in the Women's Health Initiative Life and Longevity after Cancer cohort. This study examined women ≥ 70years of age with EC with available treatment records. Change in PF was measured using the RAND-36 and compared between groups using Wilcoxon rank-sum tests. Multivariable median regression was used to compare the changes in scores while adjusting for confounding variables. Included in the study were 287 women, 150 (52.3%) women who did not receive adjuvant therapy and 137 (47.7%) who received adjuvant therapy. When comparing PF scores, there was a statistically significant difference in the median percent change in functional decline, with a greater decline in those who received adjuvant therapy (- 5.9% [- 23.5 to 0%]) compared to those who did not (0 [- 18.8 to + 6.7%]), p = 0.02). Results were not statistically significant after multivariable adjustment, but women who underwent chemotherapy had a greater percent change (median ∆ - 13.8% [- 35.5 to 0%]) compared to those who received radiation alone (median ∆ - 5.9% [- 31.3 to 0%]) or chemotherapy and radiation (median ∆ - 6.5% [- 25.8 to + 5.7%]. Older women with EC who received adjuvant therapy experienced greater change in PF than those who did not receive adjuvant therapy, particularly women who received chemotherapy. These results were not statistically significant on multivariate analysis. EC survivors may experience changes in PF because of chemotherapy and/or radiation therapy. Additional supportive care may need to be provided to older women to mitigate functional decline.

Outcomes in Enteral Access Based on Specialty and Approach: A Single-Center Three-Year Experience

IntroductionInterventional radiologic, endoscopic, and surgical approaches are commonly utilized to establish durable enteral access in adult patients. The purpose of this study is to examine differences in nutritional outcomes in a large cohort of patients undergoing enteral access creation. MethodsAdult patients who underwent enteral access procedures by interventional radiologists, gastroenterologists, and surgeons between 2018 and 2020 at a single institution were reviewed. Included access types were percutaneous endoscopic gastrostomy (PEG), open or laparoscopic gastrostomy, laparoscopic jejunostomy, and percutaneous gastrostomy (perc-G), percutaneous jejunostomy , or primary gastrojejunostomy. Results912 patients undergoing enteral access cases met the criteria for inclusion. PEGs and perc-Gs were the most common procedures. PEGs had higher Charlson scores (4.5 [3.0-6.0] versus 2.0 [1.0-2.0], P = 0.007) and lower starting albumin (3.0 [2.6-3.4] versus 3.6 [3.5-3.8] g/dL, P < 0.0001). Time to goal feeds (4 [2-6] vs 4 [3-5] d, P = 0.970), delta prealbumin (3.6 [0-6.5] versus 6.2 [2.3-10] mg/L, P = 0.145), time to access removal (160 [60-220] versus 180 [90-300] d, P = 0.998), and enteral access-related complications (19% versus 16%, P = 0.21) between PEG and perc-G were similar and differences were not statistically significant. A greater percent change in prealbumin was noted for perc-G (10 [-3-20] versus 41.7% [11-65], P = 0.002). ConclusionsDespite having higher Charlson scores and worse preoperative nutrition, there is a similar incidence of enteral access-related complications, time to goal feeds, delta prealbumin, or time to access removal between PEG and perc-G patients. Our data suggest that access approach should be made on an individual basis, accounting for anatomy and technical feasibility.

Modeling of Proliferating CD4 and CD8 T-Cell Changes to Tremelimumab Exposure in Patients with Unresectable Hepatocellular Carcinoma.

The STRIDE (Single Tremelimumab Regular Interval Durvalumab) regimen of single-dose tremelimumab 300 mg, plus durvalumab 1,500 mg every 4 weeks demonstrated potential for long-term survival in studies of unresectable hepatocellular carcinoma (uHCC; Study 22 and HIMALAYA). The aim of this analysis was to investigate changes in proliferating CD4+ Ki67+ and CD8+ Ki67+ T cells and their relationship with tremelimumab exposure in patients with uHCC. Median cell count, change from baseline, and percent change from baseline in CD4+ and CD8+ T cells peaked around 14 days after STRIDE. A model of CD4+ and CD8+ T cell response to tremelimumab exposure was developed. Patients with lower baseline T cell counts had a greater percent change from baseline in T cell response to tremelimumab, and baseline T-cell count was included in the final model. With the full covariate model, the half-maximal effective concentration (EC50 ) of tremelimumab was 6.10 μg/mL (standard error = 1.07 μg/mL); > 98.0% of patients were predicted to have a minimum plasma concentration greater than EC50 with tremelimumab 300 or 750 mg. For EC75 (9.82 μg/mL), 69.5% and 98.2% of patients were predicted to exceed the EC75 with tremelimumab 300 and 750 mg, respectively. This analysis supports the clinical hypothesis that combination anti-cytotoxic T-lymphocyte-associated antigen 4 (anti-CTLA-4) and anti-programmed cell death ligand-1 (anti-PD-L1) therapy primes an immune response that may then besustained by anti-PD-L1 monotherapy and supports the clinical utility of the STRIDE regimen in patients with uHCC. These insights may also help inform dose selection of anti-CTLA-4 plus anti-PD-L1 combination strategies.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients*

Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid = 4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection ( p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Analysis of the Resistance Change of Chemosensitive Layers to the Presence of Ammonia Vapors under Variable Conditions of Air Temperature and Humidity

The developed chemosensitive layers consisted of multi-walled carbon nanotubes (MWCNTs), reduced graphene oxide (rGO), and a conductive polymer (polyaniline-PANI) in a polymeric matrix (a polystyrene solution in methylene chloride). The layers were challenged with a test gas to determine the optimum variant in terms of sensitivity to the selected analyte and the repeatability of results. In terms of individual components, the greatest percentage change in resistance (32%) and the best repeatability were found for chemosensitive layers containing a PANI salt in the polymeric matrix. Even greater changes in resistance were exhibited by sensors containing more than one active component in the matrix: 45% for PANI + MWCNTs and 75% for PANI + rGO. The presented method of thin-layer deposition was shown to be suitable for the production of sensitive and functional sensors of ammonia vapors. The developed sensors were characterized by high repeatability and sensitivity to a harmful substance that constitutes an inhalation hazard to workers. The sensors were also analyzed for their durability and recovery as well as the ability to function under varying temperature and humidity conditions.

The Good Behaviour Game: Maintaining students' physical distancing in physical education classes during the COVID-19 pandemic.

Maintaining physical distancing is one of the most important steps to enforce in educational institutions to reduce the risk of transmission of COVID-19. However, close proximity and physical contact between students are often considered 'normal' during physical education (PE) classes, making it challenging for PE teachers to ensure physical distancing. The aim of this study was to assess the effect of the implementation of the Good Behaviour Game (GBG) in maintaining physical distancing in PE settings in times of the COVID-19 pandemic. In a quasi-experimental design, two groups were separately designated as an experimental group (20 classes involving 220 students) and a control group (20 classes involving 231 students). They were all enrolled in the eighth grade of the Tunisian education system. In the experimental group, the PE teacher managed physical distancing by administering the GBG. Physical distancing was evaluated by direct observation of videos of filmed PE sessions using a code grid. It was measured twice for the two groups using Kinovea software. Quantitative data analyses showed that the level of maintaining physical distancing increased after the GBG intervention in the experimental group (p < .001). Furthermore, greater percent changes between pre- and post-intervention were identified in the experimental group compared to the control group (120% vs 1%, respectively). The GBG was effective in ensuring students' physical distancing when implemented in PE settings.

An Observational Report of Screen Time Use Among Young Adults (Ages 18-28 Years) During the COVID-19 Pandemic and Correlations With Mental Health and Wellness: International, Online, Cross-sectional Study.

BackgroundScreen time (ST) drastically increased during the COVID-19 pandemic, but there is little research on the specific type of ST use, degree of change from before COVID-19, and possible associations with other factors. Young adults are a particular interest since previous studies have shown the detriment ST has on a young person’s health. With the combination of a life-changing pandemic, there are unreached depths regarding ST and young adults. This study aims to provide insight into these unknowns.ObjectiveThis study aims to assess ST in 3 domains (entertainment, social media [SM], and educational/professional) in young adults early in the COVID-19 pandemic; identify trends; and identify any correlations with demographics, mental health, substance abuse, and overall wellness.MethodsAn online, cross-sectional observational study was performed from September 2020 to January 2021 with 183 eligible respondents. Data were collected on ST, trauma from COVID-19, anxiety, depression, substance use, BMI, and sleep.ResultsThe average total ST during COVID-19 was 23.26 hours/week, entertainment ST was 7.98 hours/week, SM ST was 6.79 hours/week, and ST for educational or professional purposes was 8.49 hours/week. For all categories, the average ST during COVID-19 was higher than before COVID-19 (P<.001). We found ST differences between genders, student status, and continent of location. Increased well-being scores during COVID-19 were correlated with greater change in total ST (P=.01). Poorer sleep quality (P=.01) and longer sleep duration (P=.03) were associated with a greater change in entertainment ST (P=.01). More severe depression and more severe anxiety was associated with the amount of entertainment ST (P=.047, P=.03, respectively) and greater percent change in SM (P=.007, P=.002, respectively). Greater stress from COVID-19 was associated with the amount of ST for educational/professional purposes (P=.05), change in total ST (P=.006), change in entertainment ST (P=.01), and change in ST for educational/professional purposes (P=.02). Higher Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) tobacco scores were associated with greater change in total ST (P=.004), and higher pack-years were associated with greater change in SM ST (P=.003). Higher alcohol scores (P=.004) and servings of alcohol per week (P=.003) were associated with greater change in entertainment ST. Quarantining did not negatively impact these variables.ConclusionsThere is no doubt ST and worsening mental health increased during COVID-19 in young adults. However, these findings indicate there are many significant associations between ST use and mental health. These associations are more complex than originally thought, especially since we found quarantining is not associated with mental health. Although other factors need to be further investigated, this study emphasizes different types of ST and degree of change in ST affect various groups of people in discrete ways. Acknowledging these findings can help young adults optimize their mental health during pandemics.

Movement Velocity as a Determinant of Actual Intensity in Resistance Exercise.

This study aimed to analyze the acute mechanical, metabolic and EMG response to five resistance exercise protocols (REP) in the full squat (SQ) exercise performed with two velocity conditions: maximal intended velocity (MaxV) vs. half-maximal velocity (HalfV). Eleven resistance-trained men performed 10 REP (5 with each velocity conditions) in random order (72-96 h apart). The REP consisted of three sets of 8-3 repetitions against 45-65% 1RM. The percent change in countermovement jump (CMJ) height, velocity attained with the load that elicited a ~1.00 m·s-1 (V1-load), surface EMG variables and blood lactate concentration were assessed pre- vs. post-exercise protocols. MaxV resulted in greater percent changes (Δ: 12-25%) and intra-condition effect sizes (ES: 0.76-4.84) in loss of V1-load and CMJ height compared to HalfV (Δ: 10-16%; ES: 0.65-3.90) following all REP. In addition, MaxV showed higher post-exercise lactate concentration than HalfV (ES: 0.46-0.83; p<0.05). For EMG variables, only the Dimitrov index resulted in relevant changes after each REP, with MaxV showing greater magnitude of changes (23-38%) than HalfV (12-25%) across all REP. These results suggest that voluntary movement velocity is a key aspect to consider since it clearly determines the overall training intensity during resistance exercise.

Long-Term Impact of Global Pediatrics Curriculum, Experience, and Mentorship in Pediatric Residency.

ABSTRACT.Global health education is offered increasingly during residency training. The University of Minnesota has offered a global pediatrics track to residents since 2005. This study aimed to understand the impacts of a global pediatrics track on graduates’ career choices, skills, and current engagement in global health. An electronic survey was sent to 110 track graduates in February to April 2020. Data were analyzed with descriptive statistics and paired t-tests. Content analysis of written comments was conducted. The response rate was 62% overall, varying by question. Overall, 75% of responding graduates reported global pediatrics track participation affected their career choices. Eighty-four percent recalled plans to work in global health after graduation and 64% of respondents reported working in global health abroad or at home at the time of the survey. Incorporation of public health and global research represented the greatest percentage change in career plans from the time of enrollment to graduation (24% and 27%, respectively). Ninety-five percent of respondents reported that track participation improved their ability to elicit information about cultural beliefs and practices, and 86% reported improvement in cost-conscious care. An increase in global health knowledge and skills was the most common category of impact cited by respondents. Neonatal resuscitation, bubble continuous positive airway pressure, and homemade spacers for metered-dose inhalers were the most used global health-adapted skills. Our study found that graduates of the global pediatrics track perceive their participation affected their knowledge, skills, and attitudes positively, with the potential to improve clinical care and promote health equity locally and globally.

Evaluation of Diaphragmatic Function after Interscalene Block with Liposomal Bupivacaine: A Randomized Controlled Trial.

Interscalene blocks provide analgesia for shoulder surgery but also cause phrenic nerve paralysis. Liposomal bupivacaine is approved for use in interscalene blocks with the potential to provide longer pain control. However, the impact of liposomal bupivacaine on the phrenic nerve has not been evaluated. It was hypothesized that patients who received an interscalene block with both bupivacaine and liposomal bupivacaine would have a decreased diaphragmatic excursion when compared to bupivacaine alone at 24 h. This was a double-blinded study of adult patients who were randomized to receive an interscalene block with either 20 ml 0.5% bupivacaine (bupivacaine group) or 10 ml 0.5% bupivacaine plus 10 ml liposomal bupivacaine (liposomal bupivacaine group). Twenty-six patients were randomized with 22 included in the analysis. Diaphragmatic excursion (via ultrasound) and spirometry were assessed before the block, in the postanesthesia care unit, and at 24 h postblock. The primary outcome was diaphragm excursion with sigh. No adverse events were observed. At 24 h, the liposomal bupivacaine group median [25th, 75th], had a greater percent change in diaphragmatic excursion during sigh breath compared to the bupivacaine group, -24% [-30, -9] versus 9% [-8, 26], difference in location, 32 (95% CI, 12 to 52), P = 0.007. Five patients in the liposomal bupivacaine group had a greater than 25% reduction in diaphragmatic excursion at 24 h versus zero in the bupivacaine group. They also had a significantly greater percent reduction in forced expiratory volume in 1 s and forced vital capacity compared with the bupivacaine group at 24 h (median decrease of 22% vs. 2%, P = 0.006, and median decrease of 19% vs. 1%, P = 0.049, respectively). The addition of liposomal bupivacaine to bupivacaine in an interscalene block results in statistically significant reductions in diaphragm excursion and pulmonary function testing 24 h after block placement when compared to bupivacaine alone. This reduction, however, falls within the range of normal diaphragmatic function.

Correlation of DTI-Derived Measures to Therapy-Mediated Recovery after Stroke: Preliminary Findings.

Corticospinal tracts (CST) forms the basis of motor neurophysiology after stroke. Motor skill recovery has been correlated well to the microstructural properties of CST in both hemispheres. Functional imaging has opened up new possibilities of imaging functionality of cortex and fiber tracts in the brain. We studied therapy-induced changes in blood oxygenation level-dependent (BOLD) and DTI imaging on 20 chronic stroke patients at baseline, 8, and 24 weeks. All the patients were subjected to MR imaging on a 1.5 T MR scanner. We used block design for BOLD with alternate baseline and activation cycles (repetition time (TR) =4520 ms, echo time (TE) = 44 ms, slices = 31, slice thickness = 4 mm). DTI parameters were as follows: TE = 76 ms, TR = 10,726 ms, EPI factor = 127, resolution = 128 × 128 matrix, field of view = 230 mm and a slice thickness of 4.0 mm. The data was analyzed on SPSS software and tractography/DTI processing software (M/s. Siemens Medical Solutions, Erlangen Germany. The mean axial diffusivity (λ[INSIDE:1]) and radial diffusivity (λ[INSIDE:2]) in the affected hemisphere were 0. 30 and 0.18, respectively. The mean number (FN) ratio (± SD) was 0.27 ± 0.14 at baseline, 0.33 ± 0.19 at 8 weeks, and 0.41 ± 0.23 at 24 weeks. Multivariate regression analysis at baseline showed that rFA was well-correlated to the Fugl-Meyer score (regression coefficient: 0.198, F = 10.382, P = 0.001), MI followed by signal intensity. All patients had high % signal intensity after 8 weeks of physiotherapy regime with a greater percentage change in rFA as compared at follow-up suggesting that a focused exercise regime in stroke patients helps in the reconnection of neural and myelin networks. Clinical and functional recovery after stroke is well-correlated with the DTI and BOLD parameters i.e., rFA ratios, CST involvement fiber numbers, and % signal intensity of the ipsilesional cortex.

Intra-arterial combination therapy for experimental acute ischemic stroke.

Acute ischemic stroke continues to devastate millions of individuals worldwide. Current treatments work to restore blood flow but not rescue affected tissue. Our goal was to develop a combination of neuroprotective agents administered intra‐arterially following recanalization to target ischemic tissue. Using C57Bl/6J male mice, we performed tandem transient ipsilateral middle cerebral/common carotid artery occlusion, followed by immediate intra‐arterial pharmacotherapy administration through a standardized protocol. Two pharmacotherapy agents, verapamil and lubeluzole, were selected based on their potential to modulate different aspects of the ischemic cascade; verapamil, a calcium channel blocker, works in an acute fashion blocking L‐type calcium channels, whereas lubeluzole, an N‐methyl‐D‐aspartate modulator, works in a delayed fashion blocking intracellular glutamate trafficking. We hypothesized that combination therapy would provide complimentary and potentially synergistic benefit treating brain tissue undergoing various stages of injury. Physiological measurements for heart rate and pulse distention (blood pressure) demonstrated no detrimental effects between groups, suggesting that the combination drug administration is safe. Tissue analysis demonstrated a significant difference between combination and control (saline) groups in infarct volume, neuronal health, and astrogliosis. Although a significant difference in functional outcome was not observed, we did note that the combination treatment group had a greater percent change from baseline in forced motor movement as compared with controls. This study demonstrates the safety and feasibility of intra‐arterial combination therapy following successful recanalization and warrants further study.

Cold Pain Causes the Greatest Drop in Microvascular Blood Flow in Sickle Cell Disease Subjects and Normal Controls Exposed to Graded Thermal Stimuli

Background: Painful vaso-occlusive crises (VOC) are a frequent and debilitating complication of sickle cell disease (SCD). The exact mechanism of transition from steady state to VOC is not well understood although it is thought to occur due to progressive blockage of the microvasculature with rigid sickle shaped red blood cells. Thus, any trigger that decreases the microvascular blood flow increases the red blood cell transit time and can promote entrapment of sickled cells in the microvasculature and progression to VOC. Environmental factors such as exposure to cold wind and changes in weather are common triggers of VOC and have been shown to be associated with increased frequency of hospitalizations for pain in patients with SCD. There is limited experimental data in literature on the physiologic effects of these factors on peripheral perfusion in SCD.Objective: To study the effect of graded thermal stimuli on the peripheral microvascular blood flow in SCD.Methods: 17 SCD and 11 control (healthy or sickle trait) subjects aging 13 to 39 years were exposed to graded thermal stimuli via TSA- II Neurosensory analyzer thermode that was placed on the thenar eminence. Individual threshold temperatures for heat and cold detection, heat and cold pain were applied and changes in the microvascular blood flow were measured on the contralateral thumb using photo-plethysmography (PPG).The vasoconstriction response within the complex microvascular blood flow signal was detected using cross-correlation technique. In order to quantify the vasoconstriction response, we calculated mean blood flow (MBF) from the PPG amplitude during each of these stimuli and compared to the MBF at baseline.Results: Cross correlation analysis showed that cold pain caused significant vasoconstriction response in 75% of the subjects, followed by heat pain (57%), cold detection (39%) and heat detection (18%).There was a significant drop in the MBF during cold pain, heat pain and heat detection when compared to baseline MBF (p <0.001) where cold pain caused the greatest drop in MBF (Figure 1). SCD subjects trended towards greater percent change in MBF from baseline across all the threshold temperatures but there was no significant difference between the two groups. The average threshold temperatures were comparable across the two groups with no significant differences in thermal sensitivity detected between SCD and controls (Table 1).Conclusions: Exposure to graded thermal stimuli causes a progressive drop in microvascular blood flow with exposure to cold pain eliciting the strongest vasoconstriction response. The vasoconstriction occurred in the contralateral hand at an average of 10 seconds after the stimulus, suggesting a neurally mediated mechanism. Although there was no significant difference in vasoconstriction responses between SCD and controls, the drop in microvascular blood flow in sickle cell patients can increase the likelihood of entrapment of the sickled red blood cells in the microvasculature leading to vaso-occlusion. These findings are consistent with extensive reports in literature that exposure to extremes of cold weather is associated with a higher frequency of VOC. This suggests that neurally mediated decrease in the microvascular blood flow is likely an important factor in the pathophysiology behind cold exposure leading to VOC in SCD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Responses of Florida Scrub Vegetation to Water Additions from a Groundwater Treatment Project and to Hurricane Disturbance

Florida scrub is a fire-maintained shrub vegetation of well-drained, sandy soils; dominant species include several species of Quercus and Serenoa repens. In a remediation project, treated groundwater was distributed through an exfiltration gallery into intact scrub. We established eight permanent line-intercept transects (15 m length) in the site in April 2002, four close to the exfiltration gallery and four more distant from it. We sampled vegetation, <0.5 m and ≥0.5 m, along each transect and measured vegetation height at four points (0, 5, 10, 15 m) annually through 2019. The initial phase of the project operated from October 2002 to early March 2004 (494 days) and distributed 1.74 × 108 L of water. The final phase of the project occurred from March 2005 through August 2008 (1,251 days) and distributed 1.90 × 108 L of water. Pumping raised the water table near the exfiltration gallery. Vegetation height did not differ between the near and far transects initially. Vegetation height increased in the near transects by 2004 with the greatest percent change in 2003 and 2004 as did total cover ≥0.5 m. Total cover <0.5 m and bare ground were similar initially in the near and far transects and declined in the near transects by 2004. Scrub species, particularly the dominant scrub oaks, increased height and cover in response to water additions with no loss of dominant scrub species and no establishment of mesophytes. Hurricane Frances (September 2004) reduced cover ≥0.5 m the following year. Hurricane Matthew (October 2016) and Hurricane Irma (September 2017) caused greater damage including breaking limbs as reflected in reduced height and total cover ≥0.5 m probably because the older, taller scrub was more vulnerable to wind damage.