Convergent and divergent oscillatory aberrations during visuospatial processing in HIV-related cognitive impairment and Alzheimer's disease.

Adults with HIV frequently develop a form of mild cognitive impairment known as HIV-associated neurocognitive disorder (HAND), but presumably cognitive decline in older persons with HIV could also be attributable to Alzheimer's disease (AD). However, distinguishing these two conditions in individual patients is exceedingly difficult, as the distinct neural and neuropsychological features are poorly understood and most studies to date have only investigated HAND or AD spectrum (ADS) disorders in isolation. The current study examined the neural dynamics underlying visuospatial processing using magnetoencephalography (MEG) in 31 biomarker-confirmed patients on the ADS, 26 older participants who met criteria for HAND, and 31 older cognitively normal controls. MEG data were examined in the time-frequency domain, and a data-driven approach was utilized to identify the neural dynamics underlying visuospatial processing. Both clinical groups (ADS/HAND) were significantly less accurate than controls on the task and exhibited stronger prefrontal theta oscillations compared to controls. Regarding disease-specific alterations, those with HAND exhibited stronger alpha oscillations than those on the ADS in frontoparietal and temporal cortices. These results indicate both common and unique neurophysiological alterations among those with ADS disorders and HAND in regions serving visuospatial processing and suggest the underlying neuropathological features are at least partially distinct.

Movement-related beta and gamma oscillations indicate parallels and disparities between Alzheimer's disease and HIV-associated neurocognitive disorder.

People with HIV (PWH) often develop HIV-related neurological impairments known as HIV-associated neurocognitive disorder (HAND), but cognitive dysfunction in older PWH may also be due to age-related disorders such as Alzheimer's disease (AD). Discerning these two conditions is challenging since the specific neural characteristics are not well understood and limited studies have probed HAND and AD spectrum (ADS) directly. We examined the neural dynamics underlying motor processing during cognitive interference using magnetoencephalography (MEG) in 22 biomarker-confirmed patients on the ADS, 22 older participants diagnosed with HAND, and 30 healthy aging controls. MEG data were transformed into the time-frequency domain to examine movement-related oscillatory activity and the impact of cognitive interference on distinct stages of motor programming. Both cognitively impaired groups (ADS/HAND) performed significantly worse on the task (e.g., less accurate and slower reaction time) and exhibited reductions in frontal and cerebellar beta and parietal gamma activity relative to controls. Disease-specific aberrations were also detected such that those with HAND exhibited weaker gamma interference effects than those on the ADS in frontoparietal and motor areas. Additionally, temporally distinct beta interference effects were identified, with ADS participants exhibiting stronger beta interference activity in the temporal cortex during motor planning, along with weaker beta interference oscillations dispersed across frontoparietal and cerebellar cortices during movement execution relative to those with HAND. These results indicate both overlapping and distinct neurophysiological aberrations in those with ADS disorders or HAND in key motor and top-down cognitive processing regions during cognitive interference and provide new evidence for distinct neuropathology.

Resting state network connectivity alterations in HIV: Parallels with aging.

The increasing incidence of age-related comorbidities in people with HIV (PWH) has led to accelerated aging theories. Functional neuroimaging research, including functional connectivity (FC) using resting-state functional magnetic resonance imaging (rs-fMRI), has identified neural aberrations related to HIV infection. Yet little is known about the relationship between aging and resting-state FC in PWH. This study included 86 virally suppressed PWH and 99 demographically matched controls spanning 22-72 years old who underwent rs-fMRI. The independent and interactive effects of HIV and aging on FC were investigated both within- and between-network using a 7-network atlas. The relationship between HIV-related cognitive deficits and FC was also examined. We also conducted network-based statistical analyses using a brain anatomical atlas (n = 512 regions) to ensure similar results across independent approaches. We found independent effects of age and HIV in between-network FC. The age-related increases in FC were widespread, while PWH displayed further increases above and beyond aging, particularly between-network FC of the default-mode and executive control networks. The results were overall similar using the regional approach. Since both HIV infection and aging are associated with independent increases in between-network FC, HIV infection may be associated with a reorganization of the major brain networks and their functional interactions in a manner similar to aging.

Mitochondrial redox environments predict sensorimotor brain-behavior dynamics in adults with HIV.

Despite virologic suppression, people living with HIV (PLWH) remain at risk for developing cognitive impairment, with aberrations in motor control being a predominant symptom leading to functional dependencies in later life. While the neuroanatomical bases of motor dysfunction have recently been illuminated, the underlying molecular processes remain poorly understood. Herein, we evaluate the predictive capacity of the mitochondrial redox environment on sensorimotor brain-behavior dynamics in 40 virally-suppressed PLWH and 40 demographically-matched controls using structural equation modeling. We used state-of-the-art approaches, including Seahorse Analyzer of mitochondrial function, electron paramagnetic resonance spectroscopy to measure superoxide levels, antioxidant activity assays and dynamic magnetoencephalographic imaging to quantify sensorimotor oscillatory dynamics. We observed differential modulation of sensorimotor brain-behavior relationships by superoxide and hydrogen peroxide-sensitive features of the redox environment in PLWH, while only superoxide-sensitive features were related to optimal oscillatory response profiles and better motor performance in controls. Moreover, these divergent pathways may be attributable to immediate, separable mechanisms of action within the redox environment seen in PLWH, as evidenced by mediation analyses. These findings suggest that mitochondrial redox parameters are important modulators of healthy and pathological oscillations in motor systems and behavior, serving as potential targets for remedying HIV-related cognitive-motor dysfunction in the future.

Medical student attitudes to patient involvement in healthcare decision-making and research.

OBJECTIVE: Patient involvement is used to describe the inclusion of patients as active participants in healthcare decision-making and research. This study aimed to investigate incoming year 1 medical (MBChB) students' attitudes and opinions regarding patient involvement in this context. METHODS: We established a staff-student partnership to formulate the design of an online research survey, which included Likert scale questions and three short vignette scenarios designed to probe student attitudes towards patient involvement linked to existing legal precedent. Incoming year 1 medical students (n=333) were invited to participate in the survey before formal teaching commenced. RESULTS: Survey data (49 participants) indicate that students were broadly familiar with, and supportive of, patient involvement in medical treatment. There was least support for patient involvement in conducting (23.9%), contributing to (37.0%) or communicating research (32.6%), whereas there was unanimous support for patients choosing treatment from a selection of options (100%). CONCLUSION: Incoming members of the medical profession demonstrate awareness of the need to actively involve patients in healthcare decision-making but are unfamiliar with the utility and value of such involvement in research. Further empirical studies are required to examine attitudes to patient involvement in healthcare.

Reductions in Gray Matter Linked to Epigenetic HIV-Associated Accelerated Aging.

A growing literature suggests a relationship between HIV-infection and a molecular profile of age acceleration. However, despite the widely known high prevalence of HIV-related brain atrophy and HIV-associated neurocognitive disorder (HAND), epigenetic age acceleration has not been linked to HIV-related changes in structural MRI. We applied morphological MRI methods to study the brain structure of 110 virally suppressed participants with HIV infection and 122 uninfected controls age 22-72. All participants were assessed for cognitive impairment, and blood samples were collected from a subset of 86 participants with HIV and 83 controls to estimate epigenetic age. We examined the group-level interactive effects of HIV and chronological age and then used individual estimations of epigenetic age to understand the relationship between age acceleration and brain structure. Finally, we studied the effects of HAND. HIV-infection was related to gray matter reductions, independent of age. However, using epigenetic age as a biomarker for age acceleration, individual HIV-related age acceleration was associated with reductions in total gray matter. HAND was associated with decreases in thalamic and hippocampal gray matter. In conclusion, despite viral suppression, accentuated gray matter loss is evident with HIV-infection, and greater biological age acceleration specifically relates to such gray matter loss.

Case for persuasion in parental informed consent to promote rational vaccine choices.

There have been calls for mandatory vaccination legislation to be introduced into the UK in order to tackle the national and international rise of vaccine-preventable disease. While some countries have had some success associated with mandatory vaccination programmes, the Royal College of Paediatrics and Child Health (RCPCH) insist this is not a suitable option for the UK, a country which has seen historical opposition to vaccine mandates. There is a lack of comprehensive data to demonstrate a direct link between mandatory vaccination legislation and increased uptake. While there are examples whereby there has been an improvement, some studies suggest that comparable results can be obtained by strongly recommending vaccinations instead. The RCPCH insist that healthcare workers are ideally placed to engage and inform parents to make every interaction a 'vaccine opportunity'. This paper calls for a principled, rational approach to interpretations of autonomy which underpin parental informed consent. MacLean's concept of mutual persuasion could be a vehicle to ensuring parents are suitably informed of both the material risks associated with vaccine choices and to consider the rationality of their decisions, while ultimately upholding parental autonomy. It is argued that this, alongside infrastructural improvement, could create a more sustainable, long-term improvement in childhood vaccination rates in the UK than mandatory vaccination.

Towards conjoint solidarity in healthcare.

Solidarity remains an ambiguous concept despite the long political tradition pertaining to concepts of fraternity, togetherness and collective values or goals. In healthcare ethics, it has been under-explored, perhaps due to the perception that it opposes individual autonomy. However, even where autonomy is interpreted as a liberal construct, the solidaristic act may be borne out of free choice, rather than stand in opposition to it. To complement the existing scholarship, the concept of 'conjoint solidarity' in healthcare is proposed. Conjoint solidarity may be defined as 'the shared goal of all healthcare stakeholders (encapsulating all healthcare practitioners and service users) to accept or adopt a duty to assist one another to achieve improved healthcare outcomes'. The practical application of both medical autonomy and conjoint solidarity is through the process of shared decision making. An epistemic approach may be applied to 'pool information' from healthcare practitioners and patients to determine what improved healthcare outcomes are. This collective approach may also serve to address healthcare issues such exclusion, othering, paternalism and conflict of interest. Furthermore, in extending this relational approach to justice, consideration may be given to how improved healthcare may be attained in a manner that allows patients to also play their part. To this end, medical autonomy, conjoint solidarity and relational distributive justice may be considered interdependent constructs, which, when fully utilized, may help improve healthcare.

Cannabis use impacts pre-stimulus neural activity in the visual cortices of people with HIV.

People with HIV (PWH) use cannabis at a higher rate than the general population, but the influence on neural activity is not well characterized. Cannabis use among PWH may have a beneficial effect, as neuroinflammation is known to be a critical problem in PWH and cannabis use has been associated with a reduction in proinflammatory markers. Thus, it is important to understand the net impact of cannabis use on brain and cognitive function in PWH. In this study, we collected magnetoencephalographic (MEG) brain imaging data on 81 participants split across four demographically matched groups (i.e., PWH using cannabis, controls using cannabis, non-using PWH, and non-using controls). Participants completed a visuospatial processing task during MEG. Time-frequency resolved voxel time series were extracted to identify the dynamics of oscillatory and pre-stimulus baseline neural activity. Our results indicated strong theta (4-8 Hz), alpha (10-16 Hz), and gamma (62-72 Hz) visual oscillations in parietal-occipital brain regions across all participants. PWH exhibited significant behavioral deficits in visuospatial processing, as well as reduced theta oscillations and elevated pre-stimulus gamma activity in visual cortices, all of which replicate prior work. Strikingly, chronic cannabis use was associated with a significant reduction in pre-stimulus gamma activity in the visual cortices, such that PWH no longer statistically differed from controls. These results provide initial evidence that cannabis use may normalize some neural aberrations in PWH. This study fills an important gap in understanding the impact of cannabis use on brain and cognitive function in PWH.

Impact of HIV-infection on human somatosensory processing, spontaneous cortical activity, and cortical thickness: A multimodal neuroimaging approach.

HIV-infection has been associated with widespread alterations in brain structure and function, although few studies have examined whether such aberrations are co-localized and the degree to which clinical and cognitive metrics are related. We examine this question in the somatosensory system using high-resolution structural MRI (sMRI) and magnetoencephalographic (MEG) imaging of neural oscillatory activity. Forty-four participants with HIV (PWH) and 55 demographically-matched uninfected controls completed a paired-pulse somatosensory stimulation paradigm during MEG and underwent 3T sMRI. MEG data were transformed into the time-frequency domain; significant sensor level responses were imaged using a beamformer. Virtual sensor time series were derived from the peak responses. These data were used to compute response amplitude, sensory gating metrics, and spontaneous cortical activity power. The T1-weighted sMRI data were processed using morphological methods to derive cortical thickness values across the brain. From these, the cortical thickness of the tissue coinciding with the peak response was estimated. Our findings indicated both PWH and control exhibit somatosensory gating, and that spontaneous cortical activity was significantly stronger in PWH within the left postcentral gyrus. Interestingly, within the same tissue, PWH also had significantly reduced cortical thickness relative to controls. Follow-up analyses indicated that the reduction in cortical thickness was significantly correlated with CD4 nadir and mediated the relationship between HIV and spontaneous cortical activity within the left postcentral gyrus. These data indicate that PWH have abnormally strong spontaneous cortical activity in the left postcentral gyrus and such elevated activity is driven by locally reduced cortical gray matter thickness.

Epigenetic Markers of Aging Predict the Neural Oscillations Serving Selective Attention.

Chronological age remains an imperfect measure of accumulated physiological stress. Biological measures of aging may provide key advantages, allowing scientists focusing on age-related functional changes to use metrics derived from epigenetic factors like DNA methylation (DNAm), which could provide greater precision. Here we investigated the relationship between methylation-based age and an essential cognitive function that is known to exhibit age-related decline: selective attention. We found that DNAm-age predicted selective attention abilities and fully mediated the relationship between selective attention and chronological age. Using neuroimaging with magnetoencephalography, we found that gamma activity in the anterior cingulate was robustly predicted by DNAm-derived biological age, revealing the neural dynamics underlying this DNAm age-related cognitive decline. Anterior cingulate gamma activity also significantly predicted behavior on the selective attention task, indicating its functional relevance. These findings suggest that DNAm age may be a better predictor of cognitive and brain aging than more traditional chronological metrics.

Lessons from the vaginal mesh scandal: enhancing the patient-centric approach to informed consent for medical device implantation.

The vaginal mesh scandal, in which thousands of women were irreversibly maimed by polypropylene mesh, revealed multilevel failures in medical device regulation and implantation, demonstrating that patient-centric care has not yet fully transcended from policy into practice. In law, informed consent is considered by a two-stage test: reasonable treatment and patient information disclosure. The standard of reasonable treatment is determined according to what is deemed acceptable in accordance with a body of medical opinion. However, such bodies of medical opinion were vulnerable to external influence from device manufactures. Vaginal mesh manufacturers were found to have had financial links to research, royal colleges, and influential clinicians, which then influenced the basis of the evidence-based practice that often guides such bodies of medical opinion. According to the Independent Medicines and Medical Device Safety Report, patients' mesh complications were also frequently under-reported and patient-based evidence of harm disregarded. Patients were also not sufficiently informed of the material risks or reasonable alternatives to mesh, which is required of the second stage of informed consent pertaining to information disclosure. This paper makes the following recommendations: that conflict of interest disclosure be mandated, that greater value be afforded to patient-based evidence to improve evaluation of treatments, and that information disclosure for informed consent should relate to the risks, benefits, and alternatives to the surgical procedure and medical device. This will ensure that patients can evaluate whether surgeons are offering unbiased treatment options and are also informed of the potential long-term risks associated with device implantation.

Reflected appraisals across multiple reference groups: Discrepancies in self and individual delinquency.

We explore the implications of multiple reference groups for symbolic interaction explanations of delinquency. Specifically, we test the idea that dissimilarity in reflected appraisals across reference groups weakens the effect of the appraisals of a single group on behavior. We also assess whether the relative influence of different reflected appraisals is moderated by differences in the amount of time spent in and attachment to the roles taken among specific reference groups. Using data from the National Youth Survey, our findings mostly support symbolic interactionist predictions: Dissimilarity in reference groups' reflected appraisals weakens the influence of a single group's appraisals on behavior. We also found some evidence that, relatively, the more time an individual spends and the more attached they are to a role in a particular reference group, the more strongly correlated the respective appraisals are with delinquent behavior. Contrary to our predictions, we found that relatively strong attachments to one's role with their parents weakens the influence of parental reflected appraisals as a rule violator.

Participation in the Child and Adult Care Food Program is associated with fewer barriers to serving healthier foods in early care and education.

BACKGROUND: Early care and education (ECE) is an important setting for influencing young children's dietary intake. There are several factors associated with barriers to healthy eating in ECE, and recent evidence suggests that participation in the Child and Adult Care Food Program (CACFP), the primary national food assistance program in ECE, may be associated with fewer barriers to serving healthier foods. However, no prior studies have examined differences between CACFP participants and non-participants across a large, multi-state sample. This is the first study to examine the association between CACFP participation and barriers to serving healthier foods in ECE using a random sample of directors from two regions across the country. METHODS: We conducted a cross-sectional survey among a random sample of child care center directors from four states (Massachusetts, North Carolina, Rhode Island, and South Carolina). We conducted logistic and Poisson regression to calculate the odds and incidence rate ratios of reporting 1) no barriers, 2) specific barriers (e.g., cost), and 3) the total number of barriers, by CACFP status, adjusting for covariates of interest. RESULTS: We received 713 surveys (36% response rate). About half (55%) of centers participated in CACFP. The most prevalent reported barriers to serving healthier foods were cost (42%) and children's food preferences (19%). Directors from CACFP centers were twice as likely to report no barriers, compared to directors from non-CACFP centers (OR 2.03; 95% CI [1.36, 3.04]; p < 0.01). Directors from CACFP centers were less likely to report cost as a barrier (OR = 0.46; 95% [CI 0.31, 0.67]; p < 0.001), and reported fewer barriers overall (IRR = 0.77; 95% CI [0.64, 0.92]; p < 0.01), compared to directors from non-CACFP centers. CONCLUSIONS: CACFP directors reported fewer barriers to serving healthier foods in child care centers. Still, cost and children's food preferences are persistent barriers to serving healthier foods in ECE. Future research should evaluate characteristics of CACFP participation that may alleviate these barriers, and whether barriers emerge or persist following 2017 rule changes to CACFP nutrition standards.

School Cohesion Perception Discrepancy and Student Delinquency.

Research suggests that positive school environments contribute to lower levels of school disorder. Studies have also documented stark differences between how students and personnel perceive their schools. The current study examines such "perception discrepancies" as a meaningful dimension of the school environment, investigating the hypothesis that when students perceive their schools as less cohesive than their teachers, they are more likely to engage in delinquent conduct. The University of Missouri-St. Louis Comprehensive School Safety Initiative (UMSL CSSI) study allows comparisons between student and personnel perceptions of school climate among an analytic sample of 2741 students nested in 12 American middle schools (average age = 13.6; 54% female; 39% black; 39% white). The results of a series of hierarchical regression models demonstrate that students engage in higher levels of delinquency when they perceive their school environments as less cohesive, on average, than do school personnel. This suggests that discrepancies among students and personnel concerning aspects of the school climate represent a deficiency in the school's ability to protect against student delinquency.

Aberrant occipital dynamics differentiate HIV-infected patients with and without cognitive impairment.

Combination antiretroviral therapies have revolutionized the treatment of HIV infection, and many patients now enjoy a lifespan equal to that of the general population. However, HIV-associated neurocognitive disorders (HAND) remain a major health concern, with between 30% and 70% of all HIV-infected patients developing cognitive impairments during their life time. One important feature of HAND is visuo-perceptual deficits, but the systems-level neural dynamics underlying these impairments are poorly understood. In the current study, we use magnetoencephalography and advanced time series analyses to examine these neural dynamics during a visuospatial processing task in a group of HIV-infected patients without HAND (n = 25), patients with HAND (n = 18), and a group of demographically-matched uninfected controls (n = 24). All participants completed a thorough neuropsychological assessment, and underwent magnetoencephalography and structural MRI protocols. In agreement with previous studies, patients with HAND performed significantly worse than HIV-infected patients without HAND and controls on the cognitive task, in terms of increased reaction time and decreased accuracy. Our magnetoencephalography results demonstrated that both spontaneous and neural oscillatory activity within the occipital cortices were affected by HIV infection, and that these patterns predicted behavioural performance (i.e. accuracy) on the task. Specifically, spontaneous neural activity in the alpha (8-16 Hz) and gamma (52-70 Hz) bands during the prestimulus baseline period, as well as oscillatory theta responses (4-8 Hz) during task performance were aberrant in HIV-infected patients, with both spontaneous alpha and oscillatory theta activity significantly predicting accuracy on the task and neuropsychological performance outside of the magnetoencephalography scanner. Importantly, these rhythmic patterns of population-level neural activity also distinguished patients by HAND status, such that spontaneous alpha activity in patients with HAND was elevated relative to HIV-infected patients without HAND and controls. In contrast, HIV-infected patients with and without HAND had increased spontaneous gamma compared to controls. Finally, there was a stepwise decrease in oscillatory theta activity as a function of disease severity, such that the response diminished from controls to patients without HAND to patients with HAND. Interestingly, the strength of the relationship between this theta response and accuracy also dissociated patient groups in a similar manner (controls > HIV with no HAND > HIV with HAND), indicating a reduced coupling between neurophysiology and behaviour in HIV-infected patients. This study provides the first neuroimaging evidence of a dissociation between HIV-infected patients with and without HAND, and these findings shed new light on the neural bases of cognitive impairment in HIV infection.

Ethical Considerations of Medical Photography in the Management of Breast Disease.

BACKGROUND: Medical photography has become an important component of the evaluation and management of patients across many specialties. It is increasingly utilized in contemporary practice with modern smartphones and enhanced digital media. Photography can enhance and improve treatment plans and communication between providers and patients. Additionally, photography supplements education, research, and marketing in both print and social media. Ethical and medicolegal standards for medical photography, specifically for patients with breast disease, have not been formally developed to guide medical providers. PURPOSE: To provide guidelines for breast care physicians using medical photography, the Ethics Committee of the American Society of Breast Surgeons presents an updated review of the literature and recommendations for ethical and practical use of photography in patient care. METHODS: An extensive PubMed review of articles in English was performed to identify studies and articles published prior to 2018 investigating the use of medical photography in patient care and the ethics of medical photography. After review of the literature, members of the Ethics Committee convened a panel discussion to identify best practices for the use of medical photography in the breast care setting. Results of the literature and panel discussion were then incorporated to provide the content of this article. CONCLUSION: The Ethics Committee of the American Society of Breast Surgeons acknowledges that photography of the breast has become an invaluable tool in the delivery of state-of-the-art care to our patients with breast disease, and we encourage the use of this important medium. Physicians must be well informed regarding the concerns associated with medical photography of the breast to optimize its safe and ethical use in clinical practice.

A pharmacist-led medication switch protocol in an academic HIV clinic: patient knowledge and satisfaction.

BACKGROUND: Tenofovir alafenamide (TAF) is associated with less renal and bone toxicity compared with tenofovir disoproxil (TDF). TAF's recent FDA approval has spurred HIV providers to consider switching antiretroviral therapy (ART) regimens containing TDF to TAF to minimize long term risks. Patient views on the process of such medication switches have not been explored. METHODS: Patients taking elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (E/C/F/TDF) following the Food and Drug Administration's (FDA) approval of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) received medication education from an HIV pharmacist prior to switching to the tenofovir alafenamide (TAF) formulation. Patients were asked to complete a cross-sectional survey assessing satisfaction with the switch process and knowledge about the new medication 4 to 8 weeks post-switch. RESULTS: Sixty five patients completed the switch and 57 (88%) completed a follow-up survey. Most (86%) reported understanding why the switch was made, while 91% correctly identified that TAF is associated with reduced renal toxicity, and 73% correctly identified that TAF is associated with reduced bone toxicity. No statistically significant difference was found in satisfaction with or understanding of why the medication switch was made when assessed by sex, age, race, or education, but there was a trend toward significance in the distribution of answers based on education level with those with a high school diploma, General Educational Development (GED) or less being more likely to be satisfied with the medication switch (p = 0.074). CONCLUSIONS: Education from an ambulatory clinic-based HIV pharmacist resulted in high rates of patient satisfaction and understanding of the switch from TDF to TAF-containing ART.

How Does the Relationship Between Motor Skill Performance and Body Mass Index Impact Physical Activity in Preschool Children?

PURPOSE: To determine if weight status modifies the relationship between motor skill (MS) performance and physical activity (PA) in preschoolers. METHODS: Preschoolers (N = 227, age 3-5 y) were recruited from 22 preschools. Preschoolers' MS (locomotor, object control, and total MS) were assessed with the Children's Activity and Movement in Preschool Study MS protocol. PA was measured by accelerometry. Mixed linear models were used to examine the relationship of MS performance and body mass index (BMI) z score to PA. Models were adjusted for age, race, sex, and parent education, with preschool as a random effect. RESULTS: There was a significant correlation between MS performance and PA (r = .14-.17, P < .05). A significant interaction was observed between BMI z score and object control, and between BMI z score and total MS score on PA (P = .03). Preschoolers with higher BMI z scores and high object control scores engaged in significantly (P = .03) more PA than preschoolers with lower BMI z scores and high object control scores (PA = 15.04 min/h and 13.54 min/h, respectively). Similarly, preschoolers with higher BMI z scores and high total MS scores spent significantly (P = .01) more time in PA compared with those with lower BMI z scores and high total MS scores (PA = 15.65 min/h and 13.91 min/h, respectively). CONCLUSION: Preschool children's MS performance is positively correlated with PA, and BMI z score modified the relationship between MS performance and PA.

Effects of a New State Policy on Physical Activity Practices in Child Care Centers in South Carolina.

OBJECTIVES: We sought to determine the extent to which child care centers in South Carolina improved physical activity practices after a new policy took effect. METHODS: In 2012, South Carolina adopted new mandatory physical activity standards within its child care quality enhancement program. This quasi-experimental study used North Carolina, a state not making policy changes, as the comparison. Participants were 34 child care centers in South Carolina and 30 centers in North Carolina. Researchers used the Environment and Policy Assessment and Observation (EPAO) tool to conduct center observations before and after policy implementation and then conducted repeated-measures linear regression with interaction between state and time for the Physical Activity Environment Total Score and the 8 subscale scores. RESULTS: Compared with centers in North Carolina, EPAO subscale scores in South Carolina centers increased significantly for the Fixed Play Environment (P < .001) and Physical Activity Training and Education (P = .015). The state-by-time interaction of Physical Activity Environment Total Score approached statistical significance (P = .06). CONCLUSIONS: Adoption of new physical activity standards in South Carolina child care centers was associated with improvements in practices aimed at increasing children's physical activity.