Konectom™ cognitive processing speed test enables reliable remote, unsupervised cognitive assessment in people with multiple sclerosis: Exploring the use of substitution time as a novel digital outcome measure.

BACKGROUND: The Konectom™ smartphone-based cognitive processing speed (CPS) test is designed to assess processing speed and account for impact of visuomotor function on performance. OBJECTIVE: Evaluate reliability and validity of Konectom CPS Test, performed in clinic and remotely. METHODS: Data were collected from people with multiple sclerosis (PwMS) aged 18-64 years and healthy control participants (HC) matched for age, sex, and education. Remote test-retest reliability (intraclass correlation coefficients, ICC); correlation with established clinical measures (Spearman correlation coefficients); group analyses between cognitively impaired/unimpaired PwMS; and influence of age, sex, education, and upper limb motor function on CPS Test measures were assessed. RESULTS: Eighty PwMS and 66 HC participated. CPS Test measures from remote tests had good test-retest reliability (ICC of 0.67-0.87) and correlated with symbol digit modalities test (highest |ρ| = 0.80, p < 0.0001). Remote measures were stable (change from baseline < 5%) and correlated with MS disability (highest |ρ| = 0.39, p = 0.0004) measured by Expanded Disability Status Scale. CPS Test measures displayed sensitivity to cognitive impairment (highest d = 1.47). Demographics and motor function had the lowest impact on CPS Test substitution time, a measure accounting for visuomotor function. CONCLUSION: Konectom CPS Test measures provide valid, reliable remote measurements of cognitive processing speed in PwMS.

Children's environmental health and disaster resilience in Puerto Rico and the U.S. Virgin Islands.

The environment plays a significant role in the global burden of disease for children. Climate-related disasters such as the 2017 Atlantic hurricane season are increasingly contributing to this burden. United Nations designated Small Island Developing States (SIDS) like Puerto Rico and the U.S. Virgin Islands are particularly at risk due to environmental health hazards caused by natural disasters, and health care structure vulnerabilities. United Nations' Sustainable Development Goals (UN SDG), specifically UN SDG 3, 13 and 17, focus on climate impacts via promotion of health preparedness and building partnerships between different sectors of society, respectively. The Pediatric Environmental Health Specialty Unit's (PEHSU) work is consistent with these most notably via the delivery of environmental health services along with training nurses, doctors, and other health professionals, formation of partnerships and linking resources. Therefore, training a diverse array of health professionals and linking these groups to relevant community resources is of utmost importance and has the potential to enhance the effective management and early prevention of top environmental health (EH) risks. Nursing is identified as a key health sector to engage for this initiative. This article describes the work of the Federal Region 2 PEHSU in Puerto Rico and the U.S. Virgin Islands that supports health professionals' knowledge building, development of environmental health services, and promotion of wide scale access to such services for children and families. The PEHSU's work is consistent with these most notably with regards to the delivery of environmental health services in pediatrics.

Disparities in Marijuana and Tobacco Smoke Incursions Among New York City Families During Early Months of the COVID-19 Pandemic.

OBJECTIVES: Once the COVID-19 pandemic arrived in New York City (NYC), stay-at-home orders led to more time spent indoors, potentially increasing exposure to secondhand marijuana and tobacco smoke via incursions from common areas or neighbors. The objective of this study was to characterize housing-based disparities in marijuana and tobacco incursions in NYC housing during the pandemic. DESIGN: We surveyed a random sample of families from May to July 2020 and collected sociodemographic data, housing characteristics, and the presence, frequency, and pandemic-related change in incursions. SETTING: Five pediatric practices affiliated with a large NYC health care system. PARTICIPANTS: In total, 230 caregivers of children attending the practices. MAIN OUTCOME MEASURES: Prevalence and change in tobacco and marijuana smoke incursions. RESULTS: Tobacco and marijuana smoke incursions were reported by 22.9% and 30.7%, respectively. Twenty-two percent of families received financial housing support (public housing, Section-8). Compared with families in private housing, families with financial housing support had 3.8 times the odds of tobacco incursions (95% CI, 1.4-10.1) and 3.7 times the odds of worsening incursions during pandemic (95% CI, 1.1-12.5). Families with financially supported housing had 6.9 times the odds of marijuana incursions (95% CI, 2.4-19.5) and 5 times the odds of worsening incursions during pandemic (95% CI, 1.9-12.8). Children in financially supported housing spent more time inside the home during pandemic (median 24 hours vs 21.6 hours, P = .02) and were more likely to have asthma (37% vs 12.9%, P = .001) than children in private housing. CONCLUSIONS: Incursions were higher among families with financially supported housing. Better enforcement of existing regulations (eg, Smoke-Free Public Housing Rule) and implementation of additional policies to limit secondhand tobacco and marijuana exposure in children are needed. Such actions should prioritize equitable access to cessation and mental health services and consider structural systems leading to poverty and health disparities.

Integrating a Social Determinants of Health Screener at an Outpatient Pediatric Clinic in East Harlem, New York City.

In this Report from the Field, we reflect on the first six months of the 2018 implementation of a screener aimed at identifying and addressing social determinants of health (SDH) at Pediatric Associates, an outpatient clinic in East Harlem, New York City. We share descriptive statistics and reflect on lessons learned.

Developing and implementing core competencies in children's environmental health for students, trainees and healthcare providers: a narrative review.

Knowledge of the health impacts of environmental exposures (such as pollution disasters, poor air quality, water contamination, climate change) on children's health has dramatically increased in the past 40 years. The World Health Organization (WHO) estimated that 23% of all deaths worldwide were attributable to the environment, and 26% of deaths in children less than 5 years old could be prevented with removal of environmental risks factors. Yet, little has permeated medical education, leaving pediatric providers ill equipped to address these issues. To address this gap, members from the Pediatric Environmental Health Specialty Units, a United States nationwide network of academically affiliated experts who have created numerous environmental health educational materials and programs, have identified fifteen core environmental health (EH) competencies needed by health care providers to enable them to effectively address environmental health concerns. These competencies can serve as the foundation for the development and implementation of relevant educational programs. The core EH competencies are based upon these foundational elements: 1) Definition of "children's environmental health" that describes how environmental exposures (positive and negative) in early life influence the health and development in childhood and across the entire human life span 2) Children are not "little adults" and so have unique vulnerabilities to environmental hazards; 3) Environmental health inequities exist, causing some children to have a disproportionate amount of unhealthy exposures and consequently a greater risk of adverse effects; 4) Climate change will translate to numerous adverse health effects that will particularly affect children worldwide. In this article, the authors describe the core environmental health competencies and provide resources, online tools, strategies, and examples targeted to all levels of training and practice to better enable leaders and educators to bring this important content to the forefront.

Improving Patient Outcomes in the Dual Crises of Climate Change and COVID-19: Proceedings of the Third Annual Clinical Climate Change Meeting, January 8, 2021.

The tremendous global toll of the COVID-19 pandemic does not fall equally on all populations. Indeed, this crisis has exerted more severe impacts on the most vulnerable communities, spotlighting the continued consequences of longstanding structural, social, and healthcare inequities. This disparity in COVID-19 parallels the unequal health consequences of climate change, whereby underlying inequities perpetuate adverse health outcomes disproportionately among vulnerable populations. As these two crises continue to unfold, there is an urgent need for healthcare practitioners to identify and implement solutions to mitigate adverse health outcomes, especially in the face of global crises. To support this need, the 2021 Clinical Climate Change Conference held a virtual meeting to discuss the implications of the convergence of the climate crisis and COVID-19, particularly for vulnerable patient populations and the clinicians who care for them. Presenters and panelists provided evidence-based solutions to help health professionals improve and adapt their practice to these evolving scenarios. Together, participants explored the community health system and national solutions to reduce the impacts of COVID-19 and the climate crisis, to promote community advocacy, and foster new partnerships between community and healthcare leaders to combat systemic racism and achieve a more just and equitable society.

Activity Strength within Optic Flow-Sensitive Cortical Regions Is Associated with Visual Path Integration Accuracy in Aged Adults.

Spatial navigation is a cognitive skill fundamental to successful interaction with our environment, and aging is associated with weaknesses in this skill. Identifying mechanisms underlying individual differences in navigation ability in aged adults is important to understanding these age-related weaknesses. One understudied factor involved in spatial navigation is self-motion perception. Important to self-motion perception is optic flow-the global pattern of visual motion experienced while moving through our environment. A set of optic flow-sensitive (OF-sensitive) cortical regions was defined in a group of young (n = 29) and aged (n = 22) adults. Brain activity was measured in this set of OF-sensitive regions and control regions using functional magnetic resonance imaging while participants performed visual path integration (VPI) and turn counting (TC) tasks. Aged adults had stronger activity in RMT+ during both tasks compared to young adults. Stronger activity in the OF-sensitive regions LMT+ and RpVIP during VPI, not TC, was associated with greater VPI accuracy in aged adults. The activity strength in these two OF-sensitive regions measured during VPI explained 42% of the variance in VPI task performance in aged adults. The results of this study provide novel support for global motion processing as a mechanism underlying visual path integration in normal aging.

Hippocampal Resting-State Functional Connectivity Patterns are More Closely Associated with Severity of Subjective Memory Decline than Whole Hippocampal and Subfield Volumes.

The goal of this study was to examine whether hippocampal volume or resting-state functional connectivity (rsFC) patterns are associated with subjective memory decline (SMD) in cognitively normal aged adults. Magnetic resonance imaging data from 53 participants (mean age: 71.9 years) of the Boston University Alzheimer's Disease Center registry were used in this cross-sectional study. Separate analyses treating SMD as a binary and continuous variable were performed. Subfield volumes were generated using FreeSurfer v6.0, and rsFC strength between the head and body of the hippocampus and the rest of the brain was calculated. Decreased left whole hippocampal volume and weaker rsFC strength between the right body of the hippocampus and the default mode network (DMN) were found in SMD+. Cognitive Change Index score was not correlated with volumetric measures but was inversely correlated with rsFC strength between the right body of the hippocampus and 6 brain networks, including the DMN, task control, and attentional networks. These findings suggest that hippocampal rsFC patterns reflect the current state of SMD in cognitively normal adults and may reflect subtle memory changes that standard neuropsychological tests are unable to capture.

Probabilistic estimates of prenatal lead exposure at 195 toxic hotspots in low- and middle-income countries.

BACKGROUND: Prior estimates of pediatric lead-related disease burden in low- and middle-income countries (LMICs) used population estimates of maternal blood lead levels (BLLs). This approach may underestimate fetal BLLs by not considering potentially high prenatal lead exposure from toxic hotspots. OBJECTIVES: We developed a probabilistic approach to using the Adult Lead Methodology (ALM) to estimate fetal BLLs from prenatal exposure to lead-contaminated soil at hotspots in the Toxic Site Identification Program (TSIP). METHODS: We created distributions for each ALM parameter using published literature and extracted soil lead measurements from the TSIP database. Each iteration of the probabilistic ALM randomly selected values from the input distributions to generate a site-specific fetal BLL estimate. For each site, we ran 5000 model iterations, producing a site-specific fetal BLL distribution. RESULTS: 195 TSIP sites, in 33 LMICs, met our study inclusion criteria; an estimated 820,000 women of childbearing age are at risk for lead exposure at these sites. The predicted geometric means (GM) for site-specific fetal BLLs ranged from 3.3 µg/dL to 534 µg/dL, and 98% of sites had estimated GM fetal BLLs >5 µg/dL, the current reference level of the United States Centers for Disease Control and Prevention (CDC), while 11 sites had estimated GM fetal BLLs above the CDC chelation threshold of 45 µg/dL. DISCUSSION: The TSIP soil lead data and this probabilistic approach to the ALM show that pregnant women living near TSIP sites may have BLLs that put their fetus at risk for neurologic damage and other sequelae, underscoring the need for interventions to reduce lead exposure at toxic hotspots.

Home visits for pediatric asthma - A strategy for comprehensive asthma management through prevention and reduction of environmental asthma triggers in the home.

Families often struggle to manage their child's asthma. Clinicians caring for children with asthma struggle too as they are tasked with balancing the limited time available in clinic and the need to provide comprehensive care. As a direct consequence, critical gaps in asthma care remain with respect to asthma education and the identification and reduction of environmental asthma triggers in the home. A home visit model that augments clinic-based care is a viable way to fill gaps in understanding, address incomplete adherence patterns, improve disease control by shifting the focus of asthma management to reduction of environmental asthma triggers, and bring cost savings to the health care system.

Doc, can you test me for "toxic metals"? Challenges of testing for toxicants in patients with environmental concerns.

Laboratory testing is an important tool to assist clinicians in evaluation of patients with potential environmentally-related illness, however, it can be challenging to select or interpret the appropriate toxicological tests. Recent advances in analytical techniques and expanded consumer access to environmental laboratories led to a rise in laboratory testing for various environmental toxicants, including metals. However, most environmental tests have scant clinical evidence and are not validated for clinical use. While the tests themselves may not present direct harm to the patients, the results of inappropriately selected tests may lead to significant patient stress and unnecessary follow-up or treatment. Given the lack of environmental health content in medical training, pediatricians may feel ill-equipped to address most environmental issues they encounter in practice, including the interpretation of environmental toxicant lab results. This article provides an overview of how to approach a child and family with environmental health concerns about "toxic metals", select appropriate metal tests if indicated, and enlist the assistance of the Pediatric Environmental Health Specialty Units (PEHSU) for further management guidance.

Differentiating Between Healthy Control Participants and Those with Mild Cognitive Impairment Using Volumetric MRI Data.

OBJECTIVE: To determine whether volumetric measures of the hippocampus, entorhinal cortex, and other cortical measures can differentiate between cognitively normal individuals and subjects with mild cognitive impairment (MCI). METHOD: Magnetic resonance imaging (MRI) data from 46 cognitively normal subjects and 50 subjects with MCI as part of the Boston University Alzheimer's Disease Center research registry and the Alzheimer's Disease Neuroimaging Initiative were used in this cross-sectional study. Cortical, subcortical, and hippocampal subfield volumes were generated from each subject's MRI data using FreeSurfer v6.0. Nominal logistic regression models containing these variables were used to identify subjects as control or MCI. RESULTS: A model containing regions of interest (superior temporal cortex, caudal anterior cingulate, pars opercularis, subiculum, precentral cortex, caudal middle frontal cortex, rostral middle frontal cortex, pars orbitalis, middle temporal cortex, insula, banks of the superior temporal sulcus, parasubiculum, paracentral lobule) fit the data best (R2 = .7310, whole model test chi-square = 97.16, p < .0001). CONCLUSIONS: MRI data correctly classified most subjects using measures of selected medial temporal lobe structures in combination with those from other cortical areas, yielding an overall classification accuracy of 93.75%. These findings support the notion that, while volumes of medial temporal lobe regions differ between cognitively normal and MCI subjects, differences that can be used to distinguish between these two populations are present elsewhere in the brain.

Self-reported navigation ability is associated with optic flow-sensitive regions' functional connectivity patterns during visual path integration.

INTRODUCTION: Spatial navigation is a complex cognitive skill that varies between individuals, and the mechanisms underlying this variability are not clear. Studying simpler components of spatial navigation may help illuminate factors that contribute to variation in this complex skill; path integration is one such component. Optic flow provides self-motion information while moving through an environment and is sufficient for path integration. This study aims to investigate whether self-reported navigation ability is related to information transfer between optic flow-sensitive (OF-sensitive) cortical regions and regions important to navigation during environmental spatial tasks. METHODS: Functional magnetic resonance imaging was used to define OF-sensitive regions and map their functional connectivity (FC) with the retrosplenial cortex and hippocampus during visual path integration (VPI) and turn counting (TC) tasks. Both tasks presented visual self-motion through a real-world environment. Correlations predicting a positive association between self-reported navigation ability (measured with the Santa Barbara Sense of Direction scale) and FC strength between OF-sensitive regions and retrosplenial cortex and OF-sensitive regions and the hippocampus were performed. RESULTS: During VPI, FC strength between left cingulate sulcus visual area (L CSv) and right retrosplenial cortex and L CSv and right hippocampus was positively associated with self-reported navigation ability. FC strength between right cingulate sulcus visual area (R CSv) and right retrosplenial cortex during VPI was also positively associated with self-reported navigation ability. These relationships were specific to VPI, and whole-brain exploratory analyses corroborated these results. CONCLUSIONS: These findings support the hypothesis that perceived spatial navigation ability is associated with communication strength between OF-sensitive and navigationally relevant regions during visual path integration, which may represent the transformation accuracy of visual motion information into internal spatial representations. More broadly, these results illuminate underlying mechanisms that may explain some variability in spatial navigation ability.

Building New York State Centers of Excellence in Children's Environmental Health: A Replicable Model in a Time of Uncertainty.

Public health programs may be seriously affected in periods of federal retrenchment. During these times, state-based strategies provide an alternate pathway for advancing public health.A 12-year campaign to secure state support for a network of Centers of Excellence in Children's Environmental Health (CEH) promoting health of children across New York State is described. It was driven by rising rates of asthma, birth defects, developmental disorders, and other noncommunicable diseases in children; growing evidence associating hazardous environmental exposures with these conditions; and recognition that federal resources in CEH are insufficient.Critical campaign elements were (1) formation of a statewide coalition of academic health centers, health care providers, public health officials, community advocates, and other stakeholders; (2) bipartisan collaborations with legislative champions and government leaders; (3) assessment of the burden of developmental disorders and noncommunicable diseases associated with environmental exposures among children; (4) maps documenting the presence of environmental hazards in every county statewide; (5) iterative charting of a changing political landscape; and (6) persistence. The 2017 award of a 5-year, $10 million contract to establish Centers of Excellence in CEH demonstrates the value of this statewide strategy.

Age-related changes in structural connectivity are improved using subject-specific thresholding.

BACKGROUND: Deterministic diffusion tractography obtained from high angular resolution diffusion imaging (HARDI) requires user-defined quantitative anisotropy (QA) thresholds. Most studies employ a common threshold across all subjects even though there is a strong degree of individual variation within groups. We sought to explore whether it would be beneficial to use individual thresholds in order to accommodate individual variance. To do this, we conducted two independent experiments. METHOD: First, tractography of the arcuate fasciculus and network connectivity measures were examined in a sample of 14 healthy participants. Second, we assessed the effects of QA threshold on group differences in network connectivity measures between healthy young (n=19) and old (n=14) individuals. RESULTS: The results of both experiments were significantly influenced by QA threshold. Common thresholds set too high failed to produce sufficient reconstructions in most subjects, thus decreasing the likelihood of detecting meaningful group differences. On the other hand, common thresholds set too low resulted in spurious reconstructions, providing deleterious results. COMPARISON WITH EXISTING METHODS: Subject specific thresholds acquired using our QA threshold selection method (QATS) appeared to provide the most meaningful networks while ensuring that data from all subjects contributed to the analyses. CONCLUSIONS: Together, these results support the use of a subject-specific threshold to ensure that data from all subjects are included in the analyses being conducted.

Seed Location Impacts Whole-Brain Structural Network Comparisons between Healthy Elderly and Individuals with Alzheimer's Disease.

Whole-brain networks derived from diffusion tensor imaging (DTI) data require the identification of seed and target regions of interest (ROIs) to assess connectivity patterns. This study investigated how initiating tracts from gray matter (GM) or white matter (WM) seed ROIs impacts (1) structural networks constructed from DTI data from healthy elderly (control) and individuals with Alzheimer's disease (AD) and (2) between-group comparisons using these networks. DTI datasets were obtained from the Alzheimer's disease Neuroimaging Initiative database. Deterministic tractography was used to build two whole-brain networks for each subject; one in which tracts were initiated from WM ROIs and another in which they were initiated from GM ROIs. With respect to the first goal, in both groups, WM-seeded networks had approximately 400 more connections and stronger connections (as measured by number of streamlines per connection) than GM-seeded networks, but shared 94% of the connections found in the GM-seed networks. With respect to the second goal, between-group comparisons revealed a stronger subnetwork (as measured by number of streamlines per connection) in controls compared to AD using both WM-seeded and GM-seeded networks. The comparison using WM-seeded networks produced a larger (i.e., a greater number of connections) and more significant subnetwork in controls versus AD. Global, local, and nodal efficiency were greater in controls compared to AD, and between-group comparisons of these measures using WM-seeded networks had larger effect sizes than those using GM-seeded networks. These findings affirm that seed location significantly affects the ability to detect between-group differences in structural networks.

Multimodal MR-imaging reveals large-scale structural and functional connectivity changes in profound early blindness.

In the setting of profound ocular blindness, numerous lines of evidence demonstrate the existence of dramatic anatomical and functional changes within the brain. However, previous studies based on a variety of distinct measures have often provided inconsistent findings. To help reconcile this issue, we used a multimodal magnetic resonance (MR)-based imaging approach to provide complementary structural and functional information regarding this neuroplastic reorganization. This included gray matter structural morphometry, high angular resolution diffusion imaging (HARDI) of white matter connectivity and integrity, and resting state functional connectivity MRI (rsfcMRI) analysis. When comparing the brains of early blind individuals to sighted controls, we found evidence of co-occurring decreases in cortical volume and cortical thickness within visual processing areas of the occipital and temporal cortices respectively. Increases in cortical volume in the early blind were evident within regions of parietal cortex. Investigating white matter connections using HARDI revealed patterns of increased and decreased connectivity when comparing both groups. In the blind, increased white matter connectivity (indexed by increased fiber number) was predominantly left-lateralized, including between frontal and temporal areas implicated with language processing. Decreases in structural connectivity were evident involving frontal and somatosensory regions as well as between occipital and cingulate cortices. Differences in white matter integrity (as indexed by quantitative anisotropy, or QA) were also in general agreement with observed pattern changes in the number of white matter fibers. Analysis of resting state sequences showed evidence of both increased and decreased functional connectivity in the blind compared to sighted controls. Specifically, increased connectivity was evident between temporal and inferior frontal areas. Decreases in functional connectivity were observed between occipital and frontal and somatosensory-motor areas and between temporal (mainly fusiform and parahippocampus) and parietal, frontal, and other temporal areas. Correlations in white matter connectivity and functional connectivity observed between early blind and sighted controls showed an overall high degree of association. However, comparing the relative changes in white matter and functional connectivity between early blind and sighted controls did not show a significant correlation. In summary, these findings provide complimentary evidence, as well as highlight potential contradictions, regarding the nature of regional and large scale neuroplastic reorganization resulting from early onset blindness.

A systematic review of US state environmental legislation and regulation with regards to the prevention of neurodevelopmental disabilities and asthma.

BACKGROUND: While much attention is focused on national policies intended to protect human health from environmental hazards, states can also prevent environmentally mediated disease through legislation and regulation. However, relatively few analyses have examined the extent to which states protect children from chemical factors in the environment. METHODS: Using Lexis Nexis and other secondary sources, we systematically reviewed environmental regulation and legislation in the fifty states and the District of Columbia as of July 2007 intended to protect children against neurodevelopmental disabilities and asthma. RESULTS: States rarely address children specifically in environmental regulation and legislation, though many state regulations go far to limit children's exposures to environmental hazards. Northeast and Midwest states have implemented model regulation of mercury emissions, and regulations in five states set exposure limits to volatile organic compound emissions that are more stringent than US Environmental Protection Agency standards. DISCUSSION: Differences in state environmental regulation and legislation are likely to lead to differences in exposure, and thus to impacts on children's health. The need for further study should not inhibit other states and the federal government from pursuing the model regulation and legislation we identified to prevent diseases of environmental origin in children.