Early cognitive decline in older adults better predicts object than scene recognition performance.

There is an ongoing debate regarding the nature of memory deficits that occur in the early stages of mild cognitive impairment (MCI). MCI has been associated with atrophy to regions that process objects, namely perirhinal and lateral entorhinal cortices. However, it is currently unclear whether older adults with early MCI will show memory deficits that are specific to objects, or whether they will also show memory deficits for other stimulus classes, such as scenes. We tested 75 older adults using an object and scene recognition task with stimulus-specific interference (i.e., exposure to irrelevant object or scene stimuli). We found an interaction (P = 0.05) whereby scores on the Montreal Cognitive Assessment, a neuropsychological test with high sensitivity to MCI, shared a stronger relationship with object recognition than with scene recognition performance. Interestingly, this relationship was not modulated by the stimulus category of interfering items. To further explore these findings, we also tested an amnesic patient (DA) with known medial temporal lobe damage. Like older adults with early signs of MCI, DA showed poorer object recognition than scene recognition performance. Additionally, his performance was not modulated by the stimulus category of interfering material. By demonstrating that object memory is more predictive of cognitive decline than scene memory, these findings support the notion of perirhinal and lateral entorhinal cortex dysfunction in the early stages of MCI. © 2016 Wiley Periodicals, Inc.

An Oxygen Supply Is Not Enough: A Qualitative Analysis of a Pressure Swing Adsorption Oxygen Plant Program in Ethiopian Hospitals.

BACKGROUND: In response to critical gaps in medical oxygen access, 2 pressure swing adsorption (PSA) oxygen production centers were established using an ecosystem-strengthening strategy in Amhara, Ethiopia, in 2019. A qualitative study was conducted to assess enablers and bottlenecks to oxygen access at the hospital level after installation. METHODS: A variety of hospital staff (clinicians, biomedical professionals, hospital administrators, and procurement teams) across 13 hospitals procuring oxygen from the plants participated in comprehensive, semistructured focus group discussions. A thematic framework analysis approach was used to identify key themes. FINDINGS: A total of 101 individuals participated in 26 focus groups in 2021, 2 years after plants were installed. Primary themes were accessibility of supply, affordability, and hospital readiness. Respondents indicated a substantial increase in their hospital's ability to access lower-cost oxygen, with many attributing this to the locality of plants and reduced transportation barriers. However, other challenges persisted, and the emergence of COVID-19 1 year after plant installation and a civil conflict exacerbated supply shortages. Investments in equipment, supplies, and training optimized clinical utilization of oxygen and were highlighted as a need for ongoing investment. CONCLUSION: To achieve maximum impact, investments in large-scale oxygen systems must be accompanied by strategic plans to transport oxygen, reduce costs to hospitals, and provide support to clinical teams through equipment, supply procurement, and clinical training. These findings support comprehensive ecosystem approaches to strengthening oxygen access for sustainable impact.

Moderate-Severe TBI as a Progressive Disorder: Patterns and Predictors of Cognitive Declines in the Chronic Stages of Injury.

BACKGROUND: Moderate-severe traumatic brain injury (TBI) has been associated with progressive cognitive decline in the chronic injury stages in a small number of studies. OBJECTIVE: This study aimed to (i) replicate our previous findings of decline from 1 to 3+ years post-injury in a larger, non-overlapping sample and (ii) extend these findings by examining the proportion of decliners in 2 earlier time windows, and by investigating novel predictors of decline. METHODS: N = 48 patients with moderate-severe TBI underwent neuropsychological assessment at 2, 5, 12 months, and 30+ months post-injury. We employed the Reliable Change Index (RCI) to evaluate decline, stability and improvement across time and logistic regression to identify predictors of decline (demographic/cognitive reserve; injury-related). RESULTS: The proportions of patients showing decline were: 12.5% (2-5 months post-injury), 17% (5-12 months post-injury), and 27% (12-30+ months post-injury). Measures of verbal retrieval were most sensitive to decline. Of the predictors, only left progressive hippocampal volume loss from 5 to 12 months post-injury significantly predicted cognitive decline from 12 to 30+ months post-injury. CONCLUSIONS: Identical to our previous study, 27% of patients declined from 12 to 30+ months post-injury. Additionally, we found that the further from injury, the greater the proportion of patients declining. Importantly, earlier progressive hippocampal volume loss predicted later cognitive decline. Taken together, the findings highlight the need for ongoing research and treatment that target these deleterious mechanisms affecting patients in the chronic stages of moderate-severe TBI.

A Comprehensive Approach to Medical Oxygen Ecosystem Building: An Implementation Case Study in Kenya, Rwanda, and Ethiopia.

Medical oxygen is an essential treatment for life-threatening hypoxemic conditions and is commonly indicated for the clinical management of most leading causes of mortality in children aged younger than 5 years, obstetric complications at delivery, and surgical procedures. In resource-constrained settings, access to medical oxygen is unreliable due to cost, distance from production centers, undermaintained infrastructure, and a fragmented supply chain. To increase availability of medical oxygen in underserved communities, Assist International, the GE Foundation, Grand Challenges Canada, the Center for Public Health and Development (Kenya), Health Builders (Rwanda), and the National Ministries of Health and Regional Health Bureaus in Kenya, Rwanda, and Ethiopia partnered to implement a social enterprise model for the production and distribution of medical oxygen to hospitals at reduced cost. This model established pressure swing adsorption (PSA) plants at large referral hospitals and equipped them to serve as localized supply hubs to meet regional demand for medical oxygen while using revenues from cylinder distribution to subsidize ongoing costs. Since 2014, 4 PSA plants have successfully been established and sustained using a social enterprise model in Siaya, Kenya; Ruhengeri, Rwanda; and Amhara Region, Ethiopia. These plants have cumulatively delivered more than 209,708 cylinders of oxygen to a network of 183 health care facilities as of October 2022. In Ethiopia, this model costs an estimated US$7.34 per patient receiving medical oxygen over a 20-year time horizon. Altogether, this business model has enabled the sustainable provision of medical oxygen to communities with populations totaling more than 33 million people, including an estimated 5 million children aged younger than 5 years.

Remotely delivered environmental enrichment intervention for traumatic brain injury: Study protocol for a randomised controlled trial.

INTRODUCTION: Individuals with moderate-severe traumatic brain injury (m-sTBI) experience progressive brain and behavioural declines in the chronic stages of injury. Longitudinal studies found that a majority of patients with m-sTBI exhibit significant hippocampal atrophy from 5 to 12 months post-injury, associated with decreased cognitive environmental enrichment (EE). Encouragingly, engaging in EE has been shown to lead to neural improvements, suggesting it is a promising avenue for offsetting hippocampal neurodegeneration in m-sTBI. Allocentric spatial navigation (ie, flexible, bird's eye view approach), is a good candidate for EE in m-sTBI because it is associated with hippocampal activation and reduced ageing-related volume loss. Efficacy of EE requires intensive daily training, prohibitive within most current health delivery systems. The present protocol is a novel, remotely delivered and self-administered intervention designed to harness principles from EE and allocentric spatial navigation to offset hippocampal atrophy and potentially improve hippocampal functions such as navigation and memory for patients with m-sTBI. METHODS AND ANALYSIS: Eighty-four participants with chronic m-sTBI are being recruited from an urban rehabilitation hospital and randomised into a 16-week intervention (5 hours/week; total: 80 hours) of either targeted spatial navigation or an active control group. The spatial navigation group engages in structured exploration of different cities using Google Street View that includes daily navigation challenges. The active control group watches and answers subjective questions about educational videos. Following a brief orientation, participants remotely self-administer the intervention on their home computer. In addition to feasibility and compliance measures, clinical and experimental cognitive measures as well as MRI scan data are collected pre-intervention and post-intervention to determine behavioural and neural efficacy. ETHICS AND DISSEMINATION: Ethics approval has been obtained from ethics boards at the University Health Network and University of Toronto. Findings will be presented at academic conferences and submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER: Version 3, ClinicalTrials.gov Registry (NCT04331392).

Prognostic-factors for neurodegeneration in chronic moderate-to-severe traumatic brain injury: a systematic review protocol.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability. Recently, a paradigm shift in our understanding of moderate-to-severe TBI has led to its reconceptualization as a progressive neurodegenerative disorder. Widespread progressive atrophy is observed in the months and years post-injury, long after the acute effects of the injury have resolved. Some studies have begun to examine prognostic demographic, injury-related, and post-injury risk factors that contribute to these declines. A synthesis of this information, and in particular, an increased understanding of post-injury factors that may be modifiable, would improve our ability to design interventions to reduce neurodegeneration in moderate-to-severe TBI. This systematic review aims to identify prognostic factors for neural deterioration in moderate-to-severe TBI, and thereby inform future intervention research in this population. METHODS: This review protocol was informed by and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. Search strategies (designed to identify literature on prognostic factors of neurodegeneration in adults with moderate-to-severe TBI) optimized for MEDLINE, EMBASE PsychINFO, CINAHL, SportDiscus, and Cochrane Central Register of Controlled Trials will be developed with the assistance of a health sciences librarian. Retrieved studies will be screened by two team members. Studies must report on longitudinal neuroimaging (i.e., two or more scans in the same cohort) or neuroimaging in a cross-sectional study and potential prognostic factors for neurodegeneration, such as demographics (e.g., gender, age, education), injury (e.g., severity, etiology), or post-injury characteristics (e.g., type and length of therapy, activity level, mood). DISCUSSION: By identifying prognostic factors for neurodegeneration, this systematic review can help inform injury management, as well as intervention research designed to offset the effects of modifiable prognostic factors, such as low levels of cognitive or physical activity. In turn, this systematic review can increase our understanding of how to improve outcome following moderate-to-severe TBI. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019122389.

The scale of neurodegeneration in moderate-to-severe traumatic brain injury: a systematic review protocol.

BACKGROUND: Our understanding of recovery after moderate-to-severe traumatic brain injury (TBI) has shifted. Until recently, it was presumed that following a period of acute neurological vulnerability, the brain remained stable in the chronic stages of injury. However, recent research has shown neurodegeneration in the chronic stages of moderate-to-severe TBI, challenging the assumption of neurological stability. While there is extensive evidence that neurodegeneration occurs, debate remains regarding the scale and timing. This systematic review will evaluate the scale and timelines of neurodegeneration in adult patients with moderate-to-severe TBI. METHODS: Literature searches will be conducted in six electronic databases (from inception onwards), including MEDLINE, EMBASE, PsycINFO, CINAHL, SportDiscus, and Cochrane Central Register of Controlled Trials. We will include observational studies that examine neurodegenerative changes within a single sample of TBI patients or studies that compare neuroimaging outcomes between TBI patients and healthy controls. Our primary outcome is structural neuroimaging, and our secondary outcome is diffusion tensor imaging for detection of post-injury white matter changes. All screening, data extraction, and study quality appraisal will be performed independently by the same two study members. It is expected that a narrative summary of the literature will be produced. If feasible, we will conduct a random-effects meta-analysis. However, given the expected heterogeneity between studies (with respect to, for example, timing of imaging, regions imaged) we do not expect to perform a meta-analysis; rather, a narrative synthesis of our findings is expected to be performed. DISCUSSION: Understanding the scale and timelines of neurodegeneration in moderate-to-severe TBI (as well as which brain areas are most vulnerable to chronic declines) can inform intervention research designed to offset such changes. This may help improve patient outcome following moderate-to-severe TBI and, in turn, reduce the burden of the injury. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019117548.