Transforming Ethics Education Through a Faculty Learning Community: "I'm Coming Around to Seeing Ethics as Being Maybe as Important as Calculus".

Ethics is central to scientific and engineering research and practice, but a key challenge for promoting students' ethical formation involves enhancing faculty members' ability and confidence in embedding positive ethical learning experiences into their curriculums. To this end, this paper explores changes in faculty members' approaches to and perceptions of ethics education following their participation in a multi-year interdisciplinary faculty learning community (FLC). We conducted and thematically analyzed semi-structured interviews with 11 participants following the second year of the FLC. Qualitative themes suggested that, following two years of FLC participation, faculty members (1) were better able to articulate their conceptualizations of ethics; (2) became cognizant of how personal experiences, views, and beliefs informed how they introduced ethics into their curriculum; and (3) developed and lived instructional principles that guided their ethics teaching. Results thus suggested that faculty members benefitted from exploring, discussing, and teaching ethics, which (in turn) enabled them to see new opportunities and become confident in integrating ethics into their courses in meaningful ways that aligned with their scholarly identities. Taken together, these data suggest faculty became agents of change for designing, implementing, and refining ethics-related instructional efforts in STEM. This work can guide others interested in designing faculty learning communities to promote instructional skill development, faculty members' awareness of their ethical values, and their ability and agency to design and integrate ethics learning activities alongside departmental peers in an intentional and continuous manner.

Willful modulation of brain activity in disorders of consciousness.

BACKGROUND: The differential diagnosis of disorders of consciousness is challenging. The rate of misdiagnosis is approximately 40%, and new methods are required to complement bedside testing, particularly if the patient's capacity to show behavioral signs of awareness is diminished. METHODS: At two major referral centers in Cambridge, United Kingdom, and Liege, Belgium, we performed a study involving 54 patients with disorders of consciousness. We used functional magnetic resonance imaging (MRI) to assess each patient's ability to generate willful, neuroanatomically specific, blood-oxygenation-level-dependent responses during two established mental-imagery tasks. A technique was then developed to determine whether such tasks could be used to communicate yes-or-no answers to simple questions. RESULTS: Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity. In three of these patients, additional bedside testing revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment. One patient was able to use our technique to answer yes or no to questions during functional MRI; however, it remained impossible to establish any form of communication at the bedside. CONCLUSIONS: These results show that a small proportion of patients in a vegetative or minimally conscious state have brain activation reflecting some awareness and cognition. Careful clinical examination will result in reclassification of the state of consciousness in some of these patients. This technique may be useful in establishing basic communication with patients who appear to be unresponsive.

Functional neuroimaging of the vegetative state.

A number of recent studies have demonstrated a role for state-of-the-art neuroimaging methods in the assessment of patients in the vegetative state and other so-called 'disorders of consciousness'. In several cases, functional MRI has been used to show that aspects of speech perception, emotional processing, language comprehension and even conscious awareness might be retained in some patients who behaviourally meet all of the criteria that define the vegetative state. This work has profound implications for clinical care, diagnosis, prognosis and medical-legal decision making (relating to the prolongation, or otherwise, of life after severe brain injury), as well as for more basic scientific questions about the nature of consciousness and the neural representation of our own thoughts and intentions.

Bespoke Fuzzy Logic Design to Automate a Better Understanding of Running Gait Analysis.

Running gait assessment and running shoe recommendation is important for the injury prevention of runners who exhibit different skill-levels and running styles. Traditionally, running gait assessment for shoe recommendation relies upon a combination of trained professionals (e.g., sports-therapists, physiotherapists) and complex equipment such as motion or pressure sensors, often incurring a high-cost to the consumer. Despite this, assessments are still prone to subjectivity, and may differ between assessors. Alternatively, methods to provide low-cost, reproduceable gait assessment has become a necessity, especially within a habitual (low-resource) context, with many traditional methods generally unavailable due to the need of professional assistance and more recently the COVID-19 pandemic. Fuzzy logic has shown to be an effective tool in the assessment and identification of gait by providing the potential for a high-accuracy methodology, while retaining a low computational cost; ideal for applications within embedded systems. Here, we present a novel shoe recommendation fuzzy inference system from the classification of two key running gait parameters, foot strike and pronation from a single foot mounted internet of thing (IoT) enabled wearable inertial measurement unit. The fuzzy approach provides excellent (ICC > 0.9) accuracy, while significantly increasing the resolution of the gait assessment technique, providing a more detailed running gait analysis.

Diffusion weighted imaging distinguishes the vegetative state from the minimally conscious state.

The vegetative (VS) and minimally conscious (MCS) states are currently distinguished on the basis of exhibited behaviour rather than underlying pathology. Although previous histopathological studies have documented different degrees of diffuse axonal injury as well as damage to the thalami and brainstem regions in VS and MCS, these differences have not been assessed in vivo, and therefore, do not provide a measurable pathological marker to aid clinical diagnosis. Currently, the diagnostic decision-making process is highly subjective and prone to error. Indeed, previous work has suggested that up to 43% of patients in this group may be misdiagnosed. We used diffusion tensor imaging (DTI) to study the neuropathology of 25 vegetative and minimally conscious patients in vivo and to identify measures that could potentially distinguish the patients in these two groups. Mean diffusivity (MD) maps of the subcortical white matter, brainstem and thalami were generated. The MCS and VS patients differed significantly in subcortical white matter and thalamic regions, but appeared not to differ in the brainstem. Moreover, the DTI results predicted scores on the Coma Recovery Scale (p<0.001) and successfully classified the patients in to their appropriate diagnostic categories with an accuracy of 95%. The results suggest that this method may provide an objective and highly accurate method for classifying these challenging patient populations and may therefore complement the behavioural assessment to inform the diagnostic decision making process.

Validation of an inertial-based contact and swing time algorithm for running analysis from a foot mounted IoT enabled wearable.

Running gait assessment for shoe type recommendation to avoid injury often takes place within commercial premises. That is not representative of a natural running environment and may influence normal/usual running characteristics. Typically, assessments are costly and performed by an untrained biomechanist or physiotherapist. Thus, use of a low-cost assessment of running gait to recommend shoe type is warranted. Indeed, the recent impact of COVID has heightened the need for a shift toward remote assessment in general due to social-distancing guidelines and restriction of movement to bespoke assessment facilities. Mymo is a Bluetooth-enabled, inertial measurement unit (IMU) wearable worn on the foot. The wearable transmits inertial data via a smartphone application to the Cloud, where algorithms work to recommend a running shoe based upon the users/runner's pronation and foot-strike location/pattern. Here, an additional algorithm is presented to quantify ground contact time and swing/flight time within the Mymo platform to further inform the assessment of a runner's gait. A large cohort of healthy adult and adolescents (n=203, 91M:112F) were recruited to run on a treadmill while wearing the Mymo wearable. Validity of the inertial-based algorithm to quantify ground contact time was established through manual labelling of reference standard ground truth video data, with a presented accuracy between 96.6-98.7% across the two classes with respect to each foot.Clinical Relevance-This establishes the validity of a ground contact and swing times for runner with a low-cost IoT wearable.

Detecting awareness in the vegetative state.

The assessment of residual brain function in the vegetative state, is extremely difficult and depends frequently on subjective interpretations of observed spontaneous and volitional behaviors. For those patients who retain peripheral motor function, rigorous behavioral assessment supported by structural imaging and electrophysiology is usually sufficient to establish a patient's level of wakefulness and awareness. However, it is becoming increasingly apparent that, in some patients, damage to the peripheral motor system may prevent overt responses to command, even though the cognitive ability to perceive and understand such commands may remain intact. Advances in functional neuroimaging suggest a novel solution to this problem; in several recent cases, so-called "activation" studies have been used to identify residual cognitive function and even conscious awareness in patients who are assumed to be vegetative, yet retain cognitive abilities that have evaded detection using standard clinical methods.

Do vegetative patients retain aspects of language comprehension? Evidence from fMRI.

A diagnosis of vegetative state is made if a patient demonstrates no evidence of awareness of self or environment, no evidence of sustained, reproducible, purposeful or voluntary behavioural response to sensory stimuli and critically no evidence of language comprehension. For those patients who retain peripheral motor function, rigorous behavioural assessment is usually able to determine retained function. However, some patients do not retain the ability to respond overtly to command and it is becoming increasingly accepted that assessment of these patients should include techniques, which do not rely on any 'motor action' on the part of the patient. Here, we apply a hierarchical functional magnetic resonance imaging (fMRI) auditory processing paradigm to determine the extent of retained language processing in a group of 14 aetiologically heterogeneous patients who met the diagnostic criteria for either the vegetative state (n = 7), the minimally conscious state (n = 5), or who were in a severely disabled condition having emerged from a minimally conscious state (n = 2). Three different levels of speech processing were assessed: (i) Low-level auditory responses were measured using a contrast between a set of auditory stimuli and a silence baseline; (ii) mid-level speech perception processing abilities were assessed by comparing intelligible speech to unintelligible noise stimuli and (iii) high-level semantic aspects of speech processing were assessed by comparing sentences that were made difficult to understand by the presence of words that were semantically ambiguous compared to matched low-ambiguity sentences. As expected the two severely disabled, but conscious patients showed preserved speech processing at all three levels. However, contrary to the diagnostic criteria defining the vegetative state, three patients (1 traumatic, 2 non-traumatic aetiology) demonstrated some evidence of preserved speech processing. The remaining four patients (1 traumatic, 3 non-traumatic aetiology) with a diagnosis of vegetative state showed no significant activation in response to sound compared with silence. These results provide further evidence that a subset of patients fulfilling the behavioural criteria for the vegetative state retain islands of preserved cognitive function.

Using neuroimaging to detect awareness in disorders of consciousness.

The assessment of residual brain function in the vegetative state is extremely difficult and depends frequently on subjective interpretations of observed spontaneous and volitional behaviours. For those patients who retain peripheral motor function, rigorous behavioural assessment supported by structural imaging and electrophysiology is usually sufficient to establish a patient's level of wakefulness and awareness. However, it is becoming increasingly apparent that, in some patients, damage to the peripheral motor system may prevent overt responses to commands, even though the cognitive ability to perceive and understand such commands may remain intact. Advances in functional neuroimaging suggest a novel solution to this problem; in several recent cases, so-called activation studies have been used to identify residual cognitive function and even conscious awareness in patients who are assumed to be vegetative, yet retain cognitive abilities that have evaded detection using standard clinical methods.

Using functional magnetic resonance imaging to detect covert awareness in the vegetative state.

The assessment of patients with disorders of consciousness, including the vegetative state, is difficult and depends frequently on subjective interpretations of the observed spontaneous and volitional behavior. For those patients who retain peripheral motor function, rigorous behavioral assessment supported by structural imaging and electrophysiological findings is usually sufficient to establish a patient's level of wakefulness and awareness. However, it is becoming increasingly apparent that in some patients damage to the peripheral motor system may prevent overt responses to command although the cognitive ability to perceive and understand such commands may remain intact. Recent advances in functional neuroimaging suggest a novel solution to this problem; in several cases, so-called activation studies have been used to identify residual cognitive function and conscious awareness in patients who are assumed to be in a vegetative state yet retain cognitive abilities that have evaded detection using standard clinical methods.

Using a hierarchical approach to investigate residual auditory cognition in persistent vegetative state.

Persistent vegetative state is arguably one of the least understood and most ethically troublesome neurological conditions in modern medicine. The term describes a rare disorder in which patients who emerge from coma appear to be awake, but show no signs of awareness. In recent years, a number of studies have demonstrated an important role for functional neuroimaging in the identification of residual cognitive function in patients meeting the clinical criteria for persistent vegetative state. Such studies, when successful, may be particularly useful where there is a concern about the accuracy of the diagnosis and the possibility that residual cognitive function has remained undetected. Unfortunately, functional neuroimaging in persistent vegetative state is extremely complex and subject to numerous methodological, clinical and theoretical difficulties. In this chapter, we argue that in order to most effectively define the degree and extent of preserved cognitive function in persistent vegetative state, a hierarchical approach to cognition is required. To illustrate this point, a series of functional neuroimaging paradigms in the auditory domain are described, which systematically increase in complexity in terms of the auditory and/or linguistic processes required and, therefore, the degree of preserved cognition that can be inferred from "normal" patterns of activation in persistent vegetative patients. Preliminary results in a small series of patients provide a strong basis for the systematic study of possible residual cognitive function in persistent vegetative state.

Does induced hypertension reduce cerebral ischaemia within the traumatized human brain?

Recent changes in published guidelines for the management of patients with severe head injury are based on data showing that aggressive maintenance of cerebral perfusion pressure (CPP) can worsen outcome due to extracranial complications of therapy. However, it remains unclear whether CPP augmentation could reduce cerebral ischaemia, a finding which might prompt the search for CPP augmentation protocols that avoid these extracranial complications. We studied 10 healthy volunteers and 20 patients within 6 days of closed head injury. All subjects underwent imaging of cerebral blood flow (CBF), blood volume (CBV), oxygen metabolism (CMRO2) and oxygen extraction fraction (OEF) using 15O PET. In addition, for patients, the EEG power ratio index (PRI), burst suppression ratio and somatosensory evoked potentials (SEP) were obtained and CPP was increased from 68 +/- 4 to 90 +/- 4 mmHg using an infusion of norepinephrine and measurements were repeated. Following elevation of CPP, CBF and CBV were increased and CMRO2 and OEF were reduced (P < 0.001 for all comparisons). Regions with a reduction in CMRO2 were associated with the greatest reduction in OEF (r2 = 0.3; P < 0.0001). Although CPP elevation produced a significant fall in the ischaemic brain volume (IBV) (from 15 +/- 16 to 5 +/- 4 ml; P < 0.01) and improved flow metabolism coupling, the IBV was small and clinically insignificant in the majority of these patients. However, the reduction in IBV was directly related to the baseline IBV (r2 = 0.97; P < 0.001) and patients with large baseline IBV showed substantial and clinically significant reductions. CPP augmentation increased the EEG PRI (5.0 +/- 1.5 versus 4.3 +/- 1.4, P < 0.01), implying an overall decrease in neural activity, but these changes did not correlate with the reduction in CMRO2 and there was no change in SEP cortical amplitude (N20-P27). These data provide support for recent changes in recommended CPP levels for head injury management across populations of patients with significant head injury. However, they do not provide guidance on whether the intervention may be more appropriate at earlier stages after injury, or in patients selected because of high baseline IBV. It also remains unclear whether CPP values below 65 mmHg can be safely used in this population. Clarification of the significance of a reduction in CMRO2 and neuronal electrical function will require further study.

Using a modified constant prompt-delay procedure to teach spelling to students with physical disabilities.

Current research suggests that constant delay is an effective means of teaching students through near-errorless learning. The current study examined how procedures used in previous research may be modified so that constant delay can be implemented with students who have physical disabilities that prevent them from engaging in fluent academic responding. A multiple baseline design with probes was used to assess the effectiveness of a modified constant-delay procedure in teaching spelling to students with physical disabilities. This procedure was found to be effective for all 3 students.

The evaluation of an abdominal aortic tourniquet for the control of pelvic and lower limb hemorrhage.

Despite improved body armor, hemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, groin, and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a prehospital device capable of preventing pelvic and proximal lower limb hemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure, and abdominal girth were recorded. Doppler ultrasound was used to identify blood flow in the common femoral artery (CFA). The AAT was applied while the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. A total of 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, body mass index, and abdominal girth. This study shows the AAT to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving.

Mapping traumatic axonal injury using diffusion tensor imaging: correlations with functional outcome.

BACKGROUND: Traumatic brain injury is a major cause of morbidity and mortality worldwide. Ameliorating the neurocognitive and physical deficits that accompany traumatic brain injury would be of substantial benefit, but the mechanisms that underlie them are poorly characterized. This study aimed to use diffusion tensor imaging to relate clinical outcome to the burden of white matter injury. METHODOLOGY/PRINCIPAL FINDINGS: Sixty-eight patients, categorized by the Glasgow Outcome Score, underwent magnetic resonance imaging at a median of 11.8 months (range 6.6 months to 3.7 years) years post injury. Control data were obtained from 36 age-matched healthy volunteers. Mean fractional anisotropy, apparent diffusion coefficient (ADC), and eigenvalues were obtained for regions of interest commonly affected in traumatic brain injury. In a subset of patients where conventional magnetic resonance imaging was completely normal, diffusion tensor imaging was able to detect clear abnormalities. Significant trends of increasing ADC with worse outcome were noted in all regions of interest. In the white matter regions of interest worse clinical outcome corresponded with significant trends of decreasing fractional anisotropy. CONCLUSIONS/SIGNIFICANCE: This study found that clinical outcome was related to the burden of white matter injury, quantified by diffusivity parameters late after traumatic brain injury. These differences were seen even in patients with the best outcomes and patients in whom conventional magnetic resonance imaging was normal, suggesting that diffusion tensor imaging can detect subtle injury missed by other techniques. An improved in vivo understanding of the pathology of traumatic brain injury, including its distribution and extent, may enhance outcome evaluation and help to provide a mechanistic basis for deficits that remain unexplained by other approaches.

Neuroimaging and the vegetative state: resolving the behavioral assessment dilemma?

The accurate assessment of patients with impaired consciousness following a brain injury often remains a challenge to the most experienced clinician. A diagnosis of vegetative or minimally conscious state is made on the basis of the patient's clinical history and detailed behavioral examinations, which rely upon the patient being able to move or speak in order to demonstrate residual cognitive function. Recently, the development of noninvasive neuroimaging techniques has fostered a rapid increase in the exploration of residual cognitive abilities in these patient populations. However, while this body of literature is growing rapidly, at present the enterprise remains one of scientific endeavor with no inclusion in standard clinical practice. Correctly administered behavioral testing in survivors of brain injury may provide sufficient information to identify patients who are aware and are able to signal that this is the case via a recognized motor output. However, it remains possible that a subgroup of these patients may retain some level of awareness, but lack the ability to produce any motor output and are therefore mistakenly diagnosed as vegetative. It is in this latter situation that functional neuroimaging may prove to be most valuable, as a unique clinical tool for probing volition and residual cognition without necessarily assuming that the patient is able to produce any motor output.

Executive functions in the absence of behavior: functional imaging of the minimally conscious state.

One of the major challenges in the clinical evaluation of brain injury survivors is to comprehensively assess the level of preserved cognitive function in order to inform diagnostic decisions and suggest appropriate rehabilitation strategies. However, the limited (if any) capacity for producing behavior in some of these patients often limits the extent to which cognitive functions can be explored via standard bedside methods. We present a novel neuroimaging paradigm that allows the assessment of residual executive functions without requiring the patient to produce any behavioral output. In particular, we target processes such as active maintenance of information through time and willful adoption of "mind-sets" that have been proposed to require conscious awareness. Employing an fMRI block design paradigm, healthy volunteers were presented with a series of neutral (i.e., not emotionally salient) words, and alternatively instructed to listen to all the words, or to count the number of times a given target is repeated. Importantly, the perceptual stimulation in the passive listening and the counting tasks was carefully matched. Contrasted with passive listening, the counting task revealed a fronto-parietal network previously associated with target detection and working memory. Remarkably, when tested on this same procedure, a minimally conscious patient presented a highly similar pattern of activation. Furthermore, the activity in these regions appeared highly synchronous to the onset and offset of the counting blocks. Considering the close matching of sensory stimulation across the two tasks, these findings strongly suggest that the patient could willfully adopt differential "mind-sets" as a function of condition, and could actively maintain information across time. Neither cognitive function was apparent when the patient was (behaviorally) tested at the bedside. This paradigm thus exemplifies the potential for fMRI to explore high-level cognitive functions, and awareness, in the absence of any behavioral response.

Classical conditioning in the vegetative and minimally conscious state.

Pavlovian trace conditioning depends on the temporal gap between the conditioned and unconditioned stimuli. It requires, in mammals, functional medial temporal lobe structures and, in humans, explicit knowledge of the temporal contingency. It is therefore considered to be a plausible objective test to assess awareness without relying on explicit reports. We found that individuals with disorders of consciousness (DOCs), despite being unable to report awareness explicitly, were able to learn this procedure. Learning was specific and showed an anticipatory electromyographic response to the aversive conditioning stimulus, which was substantially stronger than to the control stimulus and was augmented as the aversive stimulus approached. The amount of learning correlated with the degree of cortical atrophy and was a good indicator of recovery. None of these effects were observed in control subjects under the effect of anesthesia (propofol). Our results suggest that individuals with DOCs might have partially preserved conscious processing, which cannot be mediated by explicit reports and is not detected by behavioral assessment.